A. Physical Examination Quillang, Belinda Age: 43 y/o Temperature: 36.

7 oC (digital : axillary) Respiratory Rate: 21 cpm Pulse Rate: 71 bpm Blood Pressure: 160/110 mmHg Body Parts General Survey Body built Height in relation to the clients weight Posture: standing Sitting Walking Overall hygiene and Grooming Body odors; breath Odor Signs of distress Attitude Affect or mood Appropriateness of The response Quantity and quality of speech Normal Findings Proportionate Actual Findings Interpretation Normal

Erect posture/straight Relaxed Coordinated movements Clean, neat No foul odor No stress noted Cooperative Appropriate to situation Responds appropriately

Erect posture Relaxed Not assessed Clean, neat No body/breath odors Stress noted Slightly cooperative Slightly irritated Responds appropriately Understandable, moderate pace; Exhibits thought association Logical sequence; makes sense; Has sense of reality

Normal Normal Not assessed Normal Normal

Normal Normal Normal

Understandable, moderate pace; Exhibits thought association Relevance and Logical sequence; organization of thoughts makes sense; Has sense of reality Integumentary Skin color

Normal

Varies from light to deep brown; from ruddy pink to light pink; Light brown from yellow overtones over tones olive Generally uniform except in areas exposed to sun; areas of lighter pigmented (palms, lips, nailbeds) in dark skinned people No edema Freckles, some birthmarks, some flat and raised nevi; no abrasion or other lesions Generally uniform except in areas exposed to sun

Normal

Skin color Uniformity

Normal

Presence of edema Lesions

No edema No abrasion or other lesions

Normal Normal

Skin moisture

Skin temperature Skin turgor

Moisture in skin folds and the axillae (varies with environmental temperature and humidity, body temperature and activity ) Uniform When pinched, skin springs back to previous state

Moisture in skin folds and the axillae

Normal

Uniform When pinched, skin Springs back to previous state Convex curvature, 160 degrees Smooth Intact epidermis Prompt color return

Normal Normal

Nails Nail curvature Nail texture Nail tissues Blanch test Skull Skull size and shape Skull nodules, masses, depressions Scalp Color; appearance Areas of tenderness Hair Hair evenness Hair thin/thickness Hair texture, oiliness Face Facial feature Symmetry of facial movements Eyes Eyebrows Hair distribution

Convex curvature, 160 degrees Smooth Intact epidermis Prompt color return

Normal Normal Normal Normal

Rounded, Normocephalic Smooth, absence of nodules, masses and depressions

Rounded, Normocephalic Smooth, absence of nodules, masses and depressions Lighter than the exposed areas No presence of tenderness Evenly distributed hair Thick hair Silky resilient hair

Normal Normal

Lighter than the exposed areas No tenderness Evenly distributed hair Thick hair Silky resilient hair

Normal Normal Normal Normal Normal

Symmetrical on both sides Coordinated facial Movements

Symmetrical on both sides Coordinated facial Movements

Normal Normal

Hair evenly distributed

Hair evenly distributed

Normal

Alignment

Symmetrically aligned

Symmetrically aligned

Normal

Movement

Equal movement

Equal movement

Normal

Eyelashes Hair distribution Direction of the curl

Equally distributed

Equally distributed

Normal

Curled slightly outward

Curled slightly outward

Normal

Eyelids Surface characteristics

Skin intact, no discharge, no discoloration, lids close Symmetrically

Skin intact, no discharge, no discoloration, lids close Symmetrically When lids open no Visible sclera above corneas Bilateral blinking

Normal

Position in relation to the cornea

When lids open no visible sclera above corneas

Normal

Ability to blink

Bilateral blinking

Normal

Frequency of blinking Conjunctiva Bulbar conjunctiva color, texture and presence of lesions Palpebral Conjunctiva color, texture and presence of lesion Sclera Color and clarity Cornea Clarity and texture Iris Shape and color

15 to 20 involuntary blinks

18 involuntary blinks

Normal

Transparent, capillaries sometimes evident; sclera appears white Shiny, smooth and pink or red, no lesion

Transparent, capillaries evident; sclera appears white Shiny, smooth and pink or red, no lesion

Normal

Normal

White and clear

White and clear

Normal

Transparent, shiny, smooth

Transparent, shiny, Smooth Equal in size; flat and round

Normal

Equal in size; flat and round; Color varies depending on race Black in color, equal in size, Normally 3 to 7 mm in Diameter; smooth border,

Normal

Pupils Color, shape and Symmetry of size

Black in color, equal in size, Normally 4 mm in Diameter; smooth

Normal

Round

border, round

Direct consensual

Illuminated pupil constricts Non illuminated pupil dilates

Illuminated pupil constricts Non illuminated pupil dilates

Normal

Visual Acuity Test near vision Pupils Light reaction and accommodation

Can read the newsprint Presented Pupil constrict when looking at near objects, pupil dilate when looking at far objects, Pupil converge when near object in moved toward nose

Can read the newsprint presented Pupil constrict when looking at ne objects, pupil dilate when looking at far objects, pupil converge when near object in moved toward nose No edema, no tenderness No edema, discharge

Normal

Normal

Lacrimal gland

No edema, no tenderness

Normal

Lacrimal sac

No edema, discharge

Normal

Nasolacrimal duct

No edema, tenderness

No edema, tenderness

Normal

Extraocular muscles Alignment and coordination Visual Fields Peripheral fields Ears Auricles Color, symmetry and position

Both eyes coordinated, move in unison, with parallel alignment Can see at the periphery Color same as facial skin, symmetrical, auricle aligned with the outer cantus of the eye, about 10 degrees from vertical Mobile, firm, not tender, Pinna recoils after it is folded

Both eyes coordinated, move in unison, with parallel alignment Can see at the periphery Color same as facial skin, symmetrical, auricle aligned with the outer cantus of the eye, about 10 degrees from vertical Mobile, firm, not tender, pinna recoils after it is folded

Normal

Normal Normal

Texture, elasticity and areas for tenderness External Ear Canal Ear canal for cerumen

Normal

Dry cerumen, gray-tan color; or sticky, wet cerumen in various shades of brown

Dry cerumen, brown color

Normal

Skin lesions Pus and blood Nose Shape, size, color

No lesion No pus and blood Symmetric and straight; uniform color no discharge No discharge

No lesions No pus and blood Symmetric and straight; uniform color no discharge No discharge

Normal Normal Normal

Discharge from nares Nasal cavity

Normal

Mucosa pink; clear, water discharge Nasal septum intact and in midline Air moves freely as the client breathes through the nares

Mucosa pink; clear, moist Nasal septum intact and in midline Air moves freely as the client breathes through the nares No tenderness; no lesions Not tender

Normal

Nasal septum between Nasal chambers Patency of both Nasal cavities

Normal

Normal

Bones in the nose And cartilages Sinuses Mouth Lips Symmetry of contour, color and texture

No tenderness; no lesions Not tender

Normal Normal

Uniform pink color(darker, e.g. bluish hue, in Mediterranean groups and dark skinned clients) Soft, moist, smooth texture Symmetry of contour Ability to purse lips

Uniform pink color;

Normal

Dry, chapped lips with flakes Symmetry of contour Ability to purse lips

Normal Normal Normal

Buccal Mucosa Color, moisture, texture and presence of lesions

Moist, smooth, soft, glistening and elastic texture (drier oral mucosa in elderly due to decreased salivation)

Moist, smooth, soft, glistening and elastic texture

Normal

Teeth and Gums

32 teeth, Smooth, white, shiny tooth Enamel

28 yellowish teeth, 2 lower Molars have dental fillings, Presence of dentures (4 upper molars)

Pink gums(bluish on dark Pink patched gums patches in dark skinned clients) Moist, firm texture to gums No retraction of gums Tongue/floor of the Mouth Surface of the Tongue; position, Color and texture Moist, firm texture to gums No retraction of gums

Normal Normal Normal

Central position Pink color (some brown pigmented tongue borders in dark-skinned clients); moist; slightly rough; thin whitish coating Smooth, lateral margins; no lesions Raised papillae(taste buds)

Central position Pink color; moist; slightly rough; thin whitish coating Smooth, lateral margins; no lesions Raised papillae(taste buds) Moves freely; no tenderness Smooth tongue base With prominent veins

Normal Normal

Normal

Normal

Tongue movement

Moves freely; no tenderness

Normal

Base of tongue, Mouth floor, and Frenulum Palpate tongue for nodules, lumps, or excoriated areas Palates and Uvula Color, shape, texture and presence of bony prominences

Smooth tongue base with prominent veins

Normal

Smooth with no palpable Nodules

Smooth with no Palpable nodules

Normal

Light pink, smooth, soft palate Light pink hard palate, more irregular texture

Light pink, smooth, soft palate Light pink hard palate, more irregular texture

Normal Normal

Position and mobility of the uvula Oropharyns and Tonsils Color and texture of Oropharynx Color, discharge and size of the tonsils

Positioned in midline of soft Palate

Positioned in midline of soft palate

Normal

Pink and smooth posterior Wall Pink and smooth No discharge of normal size (Grade1) or Not visible

Pink and smooth posterior wall Pink and smooth No discharge of normal size

Normal

Normal Normal

Neck and lymph Nodes Lymph nodes Enlarged lymph nodes and tenderness Trachea

Not palpable; no tenderness

Not palpable; no tenderness

Normal

Found in the middle of the neck with equal spaces No visible masses Ascends when the clients Swallows

Found in the middle of the neck with equal spaces No visible masses Ascends when the Clients swallows

Normal

Thyroid Gland

Normal Normal