Physical Assessment NAME: Patient E AGE: 68 years old SEX: M DATE: January 23, 2013 VITAL SIGNS: 1 .

.Temperature: 36.4 degrees celcius 2. Pulse Rate: 86 beats per minute 3. Respiratory Rate: 19 cycles per minute 4. Blood Pressure: 100/60 mmHg General Condition On supine position Conscious and Coherent With IVF of D5LR at 600 cc level incorporated with Amino Acid infusing well at 30 gtts/min

BODY PARTS ASSESSED SKIN

NORMAL FINDINGS Varies light to deep brown; from ruddy pink to light pink; from yellow overtone to olive. Temperature should be uniform.

ACTUAL FINDINGS Skin has scars. Pallor is noted. Temperature is uniform and within normal range.

ANALYSIS Pallor is due to decreased oxygen in Blood Circulation.

EYES

The eyelids should not be puffy. Conjunctiva should be clear and sclera should be white in color and be free from any discoloration. Extraocular muscles should be intact. The pupils should constrict equally upon penlight swinging test. There should be no blurring of vision.

Palpebral Conjunctiva is pale, no lesions, no masses palpated.

Pale palpebral conjunctiva is due to decreased oxygen in blood circulation.

Nails

Nails should be

Nails are slightly curved. refill is 4

Normal

Convex curvature. Nail Capillary

is slightly curved or flat. The capillary refill should be 3 5 seconds. Abdomen Abdomen is symmetrical, with flat, round, scaphoid contour. Lower Extremities Uniform in color, no redness and cyanosis, no edema.

seconds.

Flat Abdomen

Normal

Uniform in color, no redness and cyanosis, no edema. Normal