Professional Documents
Culture Documents
Physical Assessment
General Survey:
Vital signs are: body temperature of 35.7 C; pulse rate 82 beats per minute with
regular rhythm upon palpatation; respiratory rate of 27 cycles per minute with regular
rhytm; with equal expansion of the chest; blood pressure of systolic 130 and diastolic of
90 mmHg noted upon auscultation.
Patient is awake , conscious and coherent. Speech is adequate and converses
are well oriented. Client is responsive to questions both verbally and physically.
Skin:
Head:
Head is symmetrical upon inspection. Long, fine, black, wavy hair noted in thin
distribution. Nodular lesions with brown color and equally distributed noted on the face
upon inspection. No masses noted upon palpatation. The client doesn’t complain of
dizziness, vertigo and headache upon the interview. She has no family history of mental
disorders noted upon assessment of her/his family background.
EARS:
EARS ARE SYMMETRICAL UPON INSPECTION. TOPS OF EARS ARE ALIGNED WITH THE OUTER CANTHI
OF THE EYES NOTED SUGGESTING NO SIGN OF DOWN’S SYNDROME. PINNA AND EXTERNAL AUDITORY CANALS
ARE INTACT UPON INSPECTION. IMPACTED CERUMEN NOTED IN BOTH EARS SUGGESTING POOR HYGIENE. HE/SHE
REPORTED NO HISTORY OF EAR PAIN, RINGING IN THE EAR, OR EAR INFECTIONS. SHE/HE USES NO HEARING
Eyes:
Eyes are symmetrical upon inspection. Client has brownish black eyes.
Eyelashes and eyebrows are equally but finely distributed on both sides of the
face. Pupils are equal, round, reactive to light. No unusual discharges from the
lacrimal ducts noted upon palpatation. She/he is able to recognize size, shape,
and colors correctly. She reported use of correctional eyeglasses of 175 visual
grades on the left side and none on the right side.
Nose:
Neck:
Neck muscles are symmetrical upon inspection. Skin on the neck is intact with
good integrity. Neck lymph nodes are not swollen upon palpation. Carotid pulse is
palpable. Trachea is at the center and immovable upon palpation. No masses and
lesions noted. Voice is clear and well modulated. Client is able to perform active range
of motion exercises in the neck without mobility restrictions and pain upon assessment.
SYMMETRICAL BREAST WITH ROUND, BROWN AND REVERTED NIPPLES NOTED UPON INSPECTION.
AXILLARY HAIR NOTED WITH ADEQUATE DISTRIBUTION. NO UNUSUAL DISCHARGES UPON PALPATION OF THE
NIPPLES. LYMPH NODES ON THE AXILLAE ARE NOT SWOLLEN UPON PALPATION. SHE HAS NO FAMILY HISTORY OF
Respiratory rate of 27 cycles per minute, regular in rhythm, with noted exertion
and use of accessory muscle upon inspection. Frequent coughing accompanied by
expectoration of whitish to yellowish phlegm in moderate amount noted upon entire
duration of assessment. Resonant sounds heard upon percussion of the anterior and
posterior chest.
HEART:
Abdomen:
Abdomen is globular upon inspection. Skin integrity in the abdomen is intact with
hypertrophic scar approximately 4.5 inches long secondary to caesarian section note on
the lower abdomen. Stretch marks noted, white in color and approximately 3 to 4 inches
long noted upon inspection of the lower abdomen.
Genito- Urinary:
Client is able to void urine with yellow color, clear in character, and in
moderate amounts upon inspection. Pubic hair noted. She reported having
history of urinary tract infections during her last pregnancy. No unusual
discharges and lesions noted.
Extremities:
Upper Extremities:
Lower Extremities: