PHYSICAL ASSESSMENT Date of Physical Assessment: January 2, 2012 6:00pm Height: 5’5 Weight: 70kgs Vital Signs: BP: 120

/70 Temperature: 39.7⁰C Pulse rate: 94bpm Respiratory rate: 29cpm Pain scale: 7/10 General survey: The client is a 32 years old and appears to be oriented and alert and he attends to question appropriately. Facial features are symmetric with movements. Maintain eye contact; expressions are appropriate to the situation. The skin color is brown. The body parts are equal bilaterally and are relative proportion to each other. Clothes are appropriate to the climate and age, fit the body but not well groomed and not properly kept clean. Body Parts Skin Method of Assessment Inspection Normal Findings Varies from light to deep brown, generally uniform except in areas exposed to the sun; areas of lighter pigmentation (palms, lips, nailbeds) Freckles, some birth marks, no abrasions ( Kozier and Erb’s. techniques in clinical nursing. Physical health examination. P.58) No presence of edema Temperature is uniform When pinched, skin springs back to previous state. Resilient, evenly Actual findings Brown color, moist and flushed skin. (+) erythematous maculopapular rash all over the body Analysis and Interpretation A maculopapular rash is a type of rash characterized by a flat, red area on the skin that is covered with small confluent bumps.

Palpation

No presence of edema Skin is warm to touch due to fever With good skin turgor

Fever is present due to an infectious agent which causes an alteration in thermoregulatory set point Client manifests normal

Hair

Inspection

Hair is evenly

No presence of infestation of lice or sores. it is oily.Nails Inspection distributed and neither dry nor oily. Pupils equally rounded Pupillary activity and appear normal in appears normal and is size reactive to light. Prompt return of pink or usual color generally less than 4 seconds. Highly vascularized pink in light skinned color. the nails are smooth. findings Client manifests normal findings Palpation Smooth. positioning. presence of abnormal Pupils are equally discharges in the eyes rounded and are in normal sizes. firm and nontender Capillary refill within three to four seconds Eyes Inspection Ears Inspection When palpated. No outward pigmentations. The pupils are equally Pupillary activity rounded reactive to appears normal light and accommodation. angle of nail plate is about 160⁰. distributed. and its angle is about 160⁰. discharges are seen in cloudiness or any the patient’s eyes. The curvature of the nails of the patient is convex. They are in The ears are in normal Client manifests normal findings Client manifests normal findings Client manifests normal findings . The nails are highly vascularized and are pink in color. and his eyelashes are The eyelashes curl curl outwardly. The blanch test was done. The external surface of The external surfaces the ears should be of the ears are smooth smooth and the size and and the size and shape shape of the ears is of the ears is symmetric and symmetrical and proportional to the head proportional to the The ears are in normal head. Hair is found all over the body except for the palms and sole of the feet. firm and non-tender and its capillary refill is three seconds. his eyebrows are equal distribution in equal distribution. cloudiness or any There are no presence of abnormal pigmentations. nails returned to pink generally less than 4 seconds. Positioned symmetrical The eyes of the patient to each other are positioned symmetrically to each The eyebrows have other. There is no presence of infestation of lice or sores seen by the patient. Convex curvature. Found all over the body except for the palms and sole of the feet.

The shape is gently curved with Shape is gently curved prominences at the with prominences at the frontal and parietal frontal and parietal bones. odor. of lesions and uniform no lesion was seen and in color is uniform in color. The gnostic) for measles tongue is pink in color The tongue does not and is smooth. on the buccal mucosa The gums are pink and gums are dark in color are pathognomonic (dia smooth and smooth. bleeding. The ears are neither The client has no bulging nor perforated hearing aid and can hear normal voice tones The parts of the head The parts of the head Client manifests normal and face is proportion and face are proportion findings to each other and to each other and are symmetric symmetrical. and pus Ears are neither bulging nor perforated. No There is no evidence of evidence of lesions. the thrushes and lesions uvula is at midline. lesions. discharges. Throat. They are in line with the outer canthus of the eyes. no presence presence of discharges. pain bleeding. Frontal and maxillary When sinuses are Client manifests normal sinuses not tender palpated. The patient has bones symmetric facial movements. no presence of straight. pain and pus. there findings presence of abnormal are no presence of discharges and drainage abnormal discharges and drainage. smooth and are appear dark. white lesions normal symmetry. odor.line with the outer canthus of the eyes Head and Face Inspection Palpation Nose Inspection Palpation Mouth. Symmetric facial movements Smooth uniform Smooth uniform Client manifests normal consistency.Tonsils possess negative are not distended. there is no discharges. . absence of consistency. The lips are pink. moist. The nose Nose is symmetric and is symmetrical and straight. No swelling or redness The patient has no of the nose. septum is not perforated. Neck Inspection positioning. and characterized as in normal symmetry smooth and are in clustered. The patient’s lips Koplik's spots moist. discharges. absence of findings nodules or masses nodules or masses The nose is at the The nose of the patient Client manifests normal midline with no is at the midline. Nasal swelling or redness in septum is not the nose and his nasal perforated. there no findings tenderness reported on the maxillary and frontal area.

varicosities. rhythmic. rashes and ulcers IV seen on left hand peripheral line Client manifests normal findings Upper extremities Inspection Client manifests normal findings Thorax and Lungs Inspection Chest is symmetric and skin is intact Quiet. no masses Palpation Chest is symmetric and skin is intact. Client manifests normal findings Auscultation Heart Inspection No adventitious breath sounds No visible lifts or heaves Peripheral veins in dependent position. varicosities. Have clear breath sounds No visible lifts or heaves Tachypnea is commonly seen in patients who are experiencing severe pain. rashes and ulcers (+) Aptha ulcer in buccal mucosa Palpation No significant or palpable mass was reported at the thyroid area. No venous patterns. Quiet. the respiratory rate of the patient is 29 cpm.Tongue is smooth and is pink in color There is no presence of odor Tonsils are not distended The uvula is at midline The mouth is generally reddish/pinkish in color There is no significant or palpable mass at the thyroid area JVD is not present The lymph nodes are not distended The trachea is palpable at the midline of the neck. rhythmic. Lymph nodes are not palpable. no tenderness and masses upon palpation. Jugular vein is not distended.The trachea is palpable at the midline of the neck. and effortless respirations Temperature is uniform Chest wall is intact. and effortless respirations Temperature is uniform Chest wall is intact. No venous patterns. distention and nodular bulges at calves are present Client manifests normal findings Client manifests normal findings Palpation Full Pulsation Has Full Pulsation Client manifests normal findings . no tenderness.

dullness especially over the liver and spleen. crepitation or nodules. Joints moves smoothly . or nodules Flat and there are presence of pigmentation No lesions. has smooth coordinated movements Epigastric pain may occur with conditions that cause inflammation of the digestive organs or caused by infectious agent Client manifests normal findings Musculoskeletal Inspection Palpation Client manifests normal findings Bones has no Bones has no tenderness and swelling tenderness and swelling Joints have no tenderness and swelling. no contractures. no fasciculation. 27 were number of bowel sounds heard in one full minute (+) Tympanitic upon percussion of the abdomen Client manifests normal findings Palpation Abdomen Inspection Client manifests normal findings Client manifests normal findings Auscultation Client manifests normal findings Percussion Palpation Tympany over the stomach and gas. Not visible peristaltic movements Audible bowel sounds. has smooth coordinated movements Client manifests normal findings There is pain/tenderness noted in the epigastric area with a pain scale of 7/10 Muscles has equal size on both sides of the body. consistent tension Bladder and Liver is not palpable Muscles has equal size on both sides of the body. or tremors Bones has no deformities Joints has no swelling Muscles are firm. no contractures. or tremors Bones has no deformities Joints has no swelling Muscles are firm. Joints moves smoothly Joints have no tenderness and swelling. masses. or nodules Flat and there are presence of pigmentation No lesions. or a full bladder No tenderness. Not visible peristaltic movements Audible bowel sounds Not low-pitched and murmur sounds For bowel sounds. it is high pitched sound occur 5 to 30 times per minute Breasts even with the chest wall and uniformed in color Areola and nipples are rounded and dark brown No tenderness. masses.Breast Inspection Breasts even with the chest wall and there are presence of pigmentation Areola and nipples are rounded and dark brown No tenderness. no fasciculation. relaxed abdomen with smooth. When auscultated. crepitation or nodules. intermittent gurgling high pitched sound was heard.filled bowels.

brachioradialis. brachioradialis. Not performed Client manifests normal findings Client manifests normal findings Genitourinary Inspection Penile skin intact. urine glucose not present. patellar and Achilles reflex. anal skin is normally more pigmented. BUN 8-20 mg/dL Creatinine 0.61. Circumcised Urethral meatus is pinkish and slight like in appearance. ulcers Glasgow coma scale is 15 Positive reflexes such as biceps reflex. Rectum and Anus Intact perineal skin.Lower Extremities Neurologic System Inspection Inspection No venous pattern. varicosities. The patient was able to perform all of the said reflexes such as biceps and triceps reflex. wrinkled and brown. Position at the tip of the penis Scrotal skin is darker in color than the rest of the body and is loose Kidneys Urine color is straw. Not performed usually slightly more pigmented than the skin of the buttocks. Palpation . watery in consistency One of the clinical manifestations of amoebiasis is having diarrhea. consistency of the stool Stool color is brown. varicosities Glasgow coma scale of the patient was scored as 15 wherein eye response has the score of 4. coarser and moister than perianal skin and is usually hairless Anal sphincter has good tone Rectal wall is smooth and not tender Stool color is brown. 5 for verbal response and 6 for motor response.2mg/dL Inspection Urine is slightly yellowish in color. urine consistency clear liquid. patellar reflex and Achilles reflex No venous pattern. amber or transparent. triceps reflex. watery and ful smelling stool often containing bloodstreaked mucus. rashes.

is formed semisolid and moist Stool odor is aromatic. No presence of blood and aromatic .