Our Lady of the Pillar College-Cauayan

Cauayan City, Isabela

College of Nursing and Midwifery

HEALTH ASSESSMENT

PHYSICAL ASSESSMENT
ACTIVITY 7

THORAX AND LUNGS

Name of Patient: Patient C Age: 42 Gender: Female Birthday: July 30, 1981
Address: Amobocan Cauayan City, Isabela Occupation: Baranggay Health Worker Status: Middle Class Civil Status: Married
Chief Complaints: The patient is complaining her chest gets tight and she can't breathe even she is not doing anything and sometimes she is experiencing
hyperventilation.

Assessment Technique Actual Findings Analysis/ Interpretation

GENERAL APPEARANCE
Inspection  Has a presence of keloid in her left knee a size of 2  Normal
● Skin appearance
cm.
 Her vellus hair is properly distributed and no
presence of vitiligo.

Inspection  She is wearing a green shirt and white shorts, and  Normal
she is comfortable wearing it.
● Dress and Grooming  The clothes of the patient is neat and clean.
Inspection  Takes a bath in the morning and took a shower in  Normal
 the evening.
● Hygiene
 She brush her teeth after she eats.
 Her nails are properly trimmed and has a presence
of white nail polish.  Normal
 No presence of lies and fleas

Inspection  Her posture is symmetrically and shoulders are  Normal

aligned.
 Her position while seating is her feet are flat on the
● Posture floor. In the standing position, the weight is carried
evenly over both legs, and the back is held in a
straight position.

Inspection  The body build of the patient is rectangle.  Normal

Height: 5’2  BMI is normal because the patient
Weight: 58 is middle adult.
● Body build BMI: 23.6 (Overweight)

Inspection  Patient level of consciousness of Glasgow Coma  Normal

Scale rate of 15, because she is active and confident
by answering my question and she is paying
attention to me.
● Level of Consciousness
Inspection  The patient actively participates in the evaluation  Normal
procedure and fails to show any signs or behaviors
that indicate uncomfortable..

● Level of Comfort
Inspection  The patient's expression on their face was one of  Normal
calmness and naturalism.

Inspection  Her speech is unaffected in any way, including  Normal

clarity and completeness; they do not stumble or
● Facial Expression slur their words.
 ● Speech
VITAL SIGNS
Auscultation 36.9.0℃ Normal
● Body Temperature
Palpation 53 bpm Normal
● Pulse Rate
Inspection 9 cpm Abnormal
● Respiratory Rate -because the patient is experiencing
difficulty of breathing.

Auscultation 130/100 mmHg Abnormal

-because the patient have highblood.
● Blood Pressure

THORAX AND LUNGS

Anterior and Posterior Thorax

Inspection  Scapulae are symmetric and non protruding,  Normal

● Shape and Configuration
shoulders and scapulae are at equal horizontal
positions, middle vertebrae are aligned straight.
Anteposterior diameter is 1:2.

 No use of accessory muscles, patient is sitting up  Normal

Inspection and relaxed, breathing usually with arms sides at the
lap.
● Accessory muscles

Palpation  No presence of tenderness, pain, or usually  Normal

sensations. Temperature are equal bilaterally.
● Tenderness and crepitus

Palpation  There are no presence of neither lesions, nodules,  Normal

 cyst, or masses.

Palpation  When palpated, the fremitus can be felt on both  Normal

● Lesions or masses sides of the body or symmetric fremitus.

Palpation  Her chest expansion is symmetrical.  Normal

● Fremitus

Percussion  There is flatness over the shoulder blade and there is  Normal
resonance on the intercostal regions when
● Chest expansion percussion is applied. There is resonance along the
scapular line.

Percussion  The excursion of the diaphragm is symmetrical and  Normal

● Percussion tones is equal to 4 centimeters.

Auscultation  There is shorter inhalation and longer exhalation on  Normal

the trachea, equal length of inhalation and
exhalation between the scapular line and around the
● Diaphragmatic excursion upper sternum, thus longer inhalation and shorter
exhalation over the peripheral lung fields.

● Breath sounds  The bronchophony test produces a soft, muffled

Auscultation voice with the letter E distinguishable, the egophony  Normal
a soft, muffled voice with the letter E
distinguishable, and the whispered pectoriloquy a
very faint or no sound.

● Voice sounds