PHYSICAL EXAMINATION

Date handled: August 8, 2012 GENERAL SURVEY Appearance Received patient lying on bed, conscious, and coherent, with an ongoing IVF of D5LRS 1L x 30-31gtts/min @ the level of 750cc, hooked at the right arm, intact and infusing well. Color tone is even, afebrile. Behavior: The patient is cooperative. He responds to questions appropriately.

VITAL SIGNS: BP= 120/80 mmHg T = 37.3 C PR = 72 bpm RR = 20cpm

AREA ASSESSED SKIN a) Color

METHODS USED Inspection

NORMAL FINDINGS Varies from light to deep brown. Generally uniform except in areas exposed to sun, areas of lighter pigmentation (palms, lips, nail beds).

ACTUAL FINDINGS

REMARKS Normal

Deep brown 5 cm incision on right upper abdomen No edema Uniform (37.3 C) Moisture in the skin folds Springs back after 1 second Smooth Due to cholecystectomy Normal Normal Normal Normal Normal

b) Lesions c) Edema d) Temperature e) f) Moisture g) Turgor

Inspection and palpation Inspection Palpation

No lesion No edema Uniform with normal range (36.5 37.5 C) Moisture in the skin folds Springs back to normal when pinched (1-2 seconds) Uniform with normal range (smooth,soft)

Inspection and palpation Inspection and palpation

h) Texture HEAD a) Size and shape

Palpation

Normal

Inspection and palpation

Size and shape of the head is proportion to the body.

Heads size and shape is proportion to her body

Normal

b) Hair >color >texture

Inspection and palpation Inspection Inspection and palpation

Without infestations, shiny and smooth. Black color Fine/ thick straight, curly or kinky, silky, resilient Evenly distributed hair

No infestations and smooth hair. Black Fine, resilient

Normal Normal Normal

>distribution SKULL AND FACE a) Size and shape

Inspection

Evenly distributed

Normal

Inspection

Normocephalic and symmetrical. Symmetrical facial expressions.

Normocephalic and symmetrical. With symmetrical facial expressions.

Normal

EYES a) Eyebrows Inspection b) Sclera Inspection c) Pupil Inspection black black Normal Sclera appears white White Normal Eyebrows present bilaterally. Eyebrows are present bilaterally Normal

d) Conjunctiva EARS a) Size and shape

Inspection

Pinkish conjunctiva

Light pink conjunctiva

Normal

Inspection and palpation

Symmetrical in size and shape, consistent in the

Ears are symmetrical in size and shape, the same

Normal

facial skin color b) Hearing acuity (whisper test) c) Swelling NOSE a) Size b) Discharge c) Nares d) Septum e) Lesions MOUTH a) Lips b) Teeth c) Tongue NECK a) Neck Inspection Can move freely and without discomfort Lymph nodes are not Inspection Inspection Inspection Moist and shiny Whitish and yellowish In central position, pink, moist and slightly rough Inspection Inspection Inspection Inspection Inspection and palpation Symmetrical No nasal discharge No nasal flaring Nasal septum is midline No swelling Inspection Can hear whisper in both ears No swelling

with the skin on the face. Can hear whisper in both ears No swelling Normal

Normal

Symmetrical No nasal discharge No naal flaring Nasal septum is midline No lumps, lesions and tenderness

Normal Normal Normal Normal Normal

Dry lips Yellowish teeth with plaque In central position, pinkish, moist and slightly rough

Due to current NPO status Poor oral care Normal

Can move freely and without discomfort Lymph nodes are not

Normal

b) Lymph nodes

Palpation

Normal

palpable. c) Pulse THORAX/ CHEST a) Shape b) Lesions c) Breath sounds d) Retractions e) Heart ABDOMEN a) Color b) Contour Inspection Inspection Uniform in color Flat or rounded, abdominal contour Absence of lumps, lesions, or tenderness Inspection Palpation Auscultation Inspection Auscultation Symmetrical Absence of lumps, lesions or tenderness Absence of adventitious breath sounds Absence of retractions No heart murmurs Palpation Full pulsation on the carotid artery

palpable Full pulsation at the carotid artery Normal

Symmetrical No lesions Absence of adventitious breath sounds Absence of retractions No heart murmurs

Normal Normal Normal Normal Normal

Uniform in color Flat abdomen

Normal Normal

c) Lesions MUSCOLOSKELETAL UPPER EXTREMITIES 1. Palms 2. Nails

Inspection

Incision at right upper quadrant

Due to surgical procedure

Inspection Palpation

Uniformity in color Smooth

Uniformity in color Smooth

Normal Normal

Inspection and palpation

In convex position, nail bed is highly vascularized with a pink color (2-3 seconds) Absence of lumps, lesions or tenderness

In convex position, nail bed is highly vascularized with pink color (2 seconds) Absence of lumps, lesions and tenderness

Normal

3. Lesions LOWER EXTREMITIES 1. Feet 2. Nails

Palpation

Normal

Inspection Palpation Inspection

Uniformity in color Uniformity in color Smooth to rough Smooth In convex position, nail bed is highly vascularized with a pink color (2-3 seconds) Absence of lesion, lumps and tenderness In convex position, nail bed is highly vascularized with a pink color (2 seconds) Absence of lesion, lumps and tenderness

Normal Normal Normal

Normal

3. Lesions