General Appearance, Cephalocaudal Physical Assessment

GENERAL APPEARANCE

y

The patient is conscious, well-oriented of his present condition and showed interest with the interview by answering every question instantaneously. The patients Vital Signs are normal with a temperature of 37.3 centigrade, pulse rate of 84 beats per minute, respiration rate of 20 breaths per minute and blood pressure of 120/60. Upon receiving the patient, the patient was pale-looking and complains of pain on both lower extremities. But at the moment, the patient is looking good with no complaints of pain at all. The patient has no obvious physical deformities or abnormalities. The patient showed no sign or potential signs of distress. Physically, the patients nutritional status and body built/stature is appropriate to his age. The patient is relaxed, has an erect posture and coordinated by body movements, can freely move, flex and extend his extremities, doesnt use any assistive device and can voluntarily move. The patient has a good facial expression without grimacing. The patients mood is appropriate to the situation, has appropriate response, comfortable and calm. The patient is understandable, and moderate in pace.

y

The patient physically looks clean and neat.

y

y

y

y y y y

y y

CEPHALOCAUDAL PHYSICAL ASSESSMENT y

SKIN The patients skin is uniformly brown in color except in areas exposed to the sun, has no lesions, edema or abrasions, is not moist because of the air ventilated environment, has uniform temperature, and when pinched, the skin springs back to the previous state. The tissues surrounding the nails of the patient are intact. And when blanched test performed, color of the nail of the client returns into pink in less than 4 seconds.

y

HEAD

AND FACE

The patients scalp is lighter than the color of his skin and has no areas of tenderness. The hair is evenly distributed and is thick. The patient has symmetric facial movements. y

EYE

The patients eyebrows have evenly distributed hair, has intact skin, symmetrically aligned, and has equal movement. The conjunctiva is transparent, capillaries sometimes evident, and sclera appears white and clear. The cornea is transparent, shiny and smooth, details of iris are visible. The iris is brown, flat and round. The patients visual acuity is normal. y

EAR

The patients external ear canal is dry, has presence of hair follicles, no pus or blood. Normal voice tones are audible to patient. Sound is heard on both or localized at the center of the head. Ear is without masses. y

NOSE The patient has no tenderness on sinuses. The nose is in the midline, has no discharges, no nasal flaring, both nares are patent, and no bone and cartilage deviation noted on palpation.

y

MOUTH

AND THROAT

The patients buccal mucosa is uniformly pink in color, moist, smooth, soft, glistening and elastic in texture, and has no lesions. Teeth are white to yellowish in color, gums are pink, moist, firm, has no retraction and bleeding of gums. Tongue is pink, has thin whitish color. and have no discharges.

Uvula

is positioned in the midline of soft palate. The tonsils are pink in color,

y

NECK The trachea is on central placement in the midline of the neck, spaces are equal on both sides. The thyroid gland is not visible in inspection, gland ascends during swallowing, no masses palpated.

y

CHEST (POSTERIOR AND LATERAL) Posterior

thorax is asymmetric, ribs are sloped downward, and muscle development is equal. Spines are slightly

aligned, are uniform in temperature, have no tenderness and masses. Chest is symmetric upon expansion. y

CHEST (ANTERIOR) Breathing pattern is quiet, rhythmic and effortless. Chest is symmetric upon expansion, has flat sound on the part with heavy muscles and bony prominences, tympani on the stomach, dullness on the liver and spleen, bronchovesicular and vesicular.

y

HEART

The patients heart has no palpable pulsation over the aortic, pulmonic, and mitral valves, no noted abnormal heaves, and thrills felt over the apex, and no abnormal heart sounds is heard like murmurs. y

UPPER EXTREMITIES

Both extremities are equal in size, have the same contour with prominences of joints, no involuntary movements, no edema, color is even, temperature is warm and even, has equal contraction and even, can perform complete range of  motion, no crepitus noted on joints, and can counter act gravity and resistance on RO M. y

ABDOMEN The patients abdomen skin color is uniform, no lesions, have scar, flat, rounded, no tenderness noted, with smooth and consistent tension, and has no muscle guarding.

y

LOWER EXTREMITIES Both extremities are equal in size, have the same contour with prominences of joints, no involuntary movements, no edema, color is even, temperature is warm and even, has equal contraction and even, can perform complete range of  motion, no crepitus noted on joints, and can counter act gravity and resistance on RO M.

y

MUSCULOSKELETAL

The patients muscles are bilaterally symmetric, has no contractures and tremors, normal muscle tension, adequate strength of the muscle. The bones are uniform in structure, no deformities, tenderness or edema. Joints are not tender, has smooth movement and no nodules. y

ANUS, RECTUM AND PROSTATE (NOT ASSESSED)