HEAD

There were no significant abnormalities found in the head part of the clients during the physical
assessment. Her skull is a smooth contour condition, round and symmetrical with frontal,
parietal, and occipital prominences. Thus there was no presence of nodules and masses. She
was able to move her eyebrows up and down and closed her eyes tightly. It is noted to move
coordinately. No facial edema and abnormalities like tics and tremors were noted. Her eyebrows
are thick, high, sharp and were equally distributed. She was able to move her eyes using the six
cardinal plane and was noted to move coordinately. The eye lashes were equally distributed;
with regards to her eyelids there were a presence of dark circles under her eyes. The details of
the iris are visible, circular and equal in size with brown color, pupils were reactive to stimulation
when penlight was used.

When the color, symmetry, and size of auricles were inspected, It was observed that the color is
still the same as what facial skin color of the client. The size was normal and it was both soft
and firm to touch; It is both symmetrical. During the interview the client can hear clearly and
seems responsive to the questions with a normal voice tone even if we are far. The nose was
noted to be straight and symmetrical, no found of any significant abnormalities or discharge
lesions, swelling nor nasal flaring and is in fair color. Mrs. M lips color is dark and slightly pale
and dry. She can move her lips freely, can open her mouth fully without any discomfort and is
symmetrically. There was no presence of dental caries and her teeth were evenly aligned and
proportioned. She has a brownish color of gums and is moist. When her tongue was inspected,
no lesion was noted. The color is pink, has a thin whitish coaching, is moist and the uvula is
located at the center.

NECK

During the assessment there were no abnormalities noted like masses or swellings, the size of
the sternocleidomastoid and trapezius muscles were equal. Mrs. M is able to move her head
freely, there was good coordination and observation of the head movement. The trachea has
equal space on both sides. When the trachea was palpated, it was noted to be positioned
centrally in the neck. The thyroid gland is soft and palpable, when the patient asks to drink water
and swallow, it is noted to rise along with thyroid and cricoid cartilage during swallowing.

The trachea showed no enlargement, masses or nodules. On inspection, the thorax was found
to be symmetric. The right and left shoulders are aligned, the column is straight, and the back
spine is vertically aligned. It was observed how the client breathed, including her rhythmic and
effortless breathing as well as her respiratory rate. She has equal peripheral pulses on both
sides, indicating their presence. As during assessment her pulse rate and respiratory rate as
taken noted, were within normal range.

ABDOMEN
The abdomen was being assessed for the skin integrity and it was noted to have uniform in
color, except for the stretch marks scars appearing on her abdomen. Neither, there were no
significant abnormalities or skin lesions. Bowel sounds present and normoactive. Patient denies
pain with palpation and no masses were noted.

MUSCULOSKELETAL SYSTEM

The size of the muscles on both sides of the body was equal for the upper and lower
extremities. No tremors or contractures were noted, and there are no observed abnormalities or
misalignments of the bones. There were no observations of swelling or tenderness. Her joints
showed no signs of swollen areas, nodules or any discomfort.

Mrs. M, 21 y/o Physical Assessment

Vital signs

BP 120/100

Temperature 36.3 C

Pulse Rate 86 beats per minute

Respiratory Rate 20 beats per minute

Skin

Color The color of the skin is brown

Lesion No macule or papule noted

Vascularity No edema, vascular, purpuric lesions was

noted

Moisture Moisture accords to hot weather

Texture Smooth and firm

Temperature Warm

Mobility and Turgor Skin rapidly resumed to its original state

Nails The nails are clean and clipped short

Head
Hair Color is black, long, straight, and silky

Scalp There is no found dandruffs, lice or lesions

Skull The size, shape were normal and are

symmetry.

Face The face is round in shape

Forehead Smooth and no wrinkles found

Eyes Color is black and can move the six cardinal

plane

Ears Hearing function is normal and no odor or

swelling is noted

Nose Symmetrical with no nasal cavity,

discoloration, and swelling or malformations

Mouth No swelling or inflammation noted

Neck No tenderness and can move or flex easily

Shoulder and Arms Both symmetry

Elbow No swelling and deformities noted

Forearms Can extend and flex properly

Hand and Wrist No swelling or deformities noted

Leg and Knees Symmetry and no swelling or deformities

noted

Foot No deformities and clubfoot noted

Mrs M Son, Physical Assessment

Vital signs

Temperature 36.7 C

Pulse Rate 39 beats per minute

Cardiac Rate 120 beats per minute

Skin

Color The color of the skin is brown

Lesion No macule or papule noted

Vascularity No edema, vascular, purpuric lesions was

noted

Moisture Moisture accords to hot weather

Texture Smooth and firm

Temperature Warm

Mobility and Turgor Skin rapidly resumed to its original state

Nails The nails are clean and clipped short

Head

Hair Color is black, short, curly, and silky

Scalp There is no found dandruffs, lice or lesions

Skull The size, shape were normal and are

symmetry.

Face The face is round in shape

Forehead Smooth and no wrinkles found

Eyes Color is black and can move the six cardinal

plane

Ears Hearing function is normal and no odor or

swelling is noted

Nose Nasal asymmetry was noted with no signs of

swelling and discoloration found.

Mouth Cleft lip and palate was noted

Neck No tenderness and can move or flex easily

Shoulder and Arms Both symmetry

Elbow No swelling and deformities noted

Forearms Can extend and flex properly

Hand and Wrist No swelling or deformities noted

Leg and Knees Symmetry and no swelling or deformities

noted

Foot No deformities and clubfoot noted

Mrs. M brother, 19 y/o Physical Assessment

Vital signs

BP 120/70

Temperature 36 C

Pulse Rate 80 beats per minute

Respiratory Rate 19 beats per minute

Skin

Color The color of the skin is brown

Lesion No macule or papule noted

Vascularity No edema, vascular, purpuric lesions was

noted

Moisture Moisture accords to hot weather

Texture Smooth and firm

Temperature Warm

Mobility and Turgor Skin rapidly resumed to its original state

Nails The nails are clean and clipped short

Head

Hair Color is black, short and silky

Scalp There is no found dandruffs, lice or lesions

Skull The size, shape were normal and are
symmetry.

Face The face is round in shape

Forehead Smooth and no wrinkles found

Eyes Color is black and can move the six cardinal

plane

Ears Hearing function is normal and no odor or

swelling is noted

Nose Symmetrical with no nasal cavity,

discoloration, and swelling or malformations

Mouth No swelling or inflammation noted

Neck No tenderness and can move or flex easily

Shoulder and Arms Both symmetry

Elbow No swelling and deformities noted

Forearms Can extend and flex properly

Hand and Wrist No swelling or deformities noted

Leg and Knees Symmetry and no swelling or deformities

noted

Foot No deformities and clubfoot noted