PHYSICAL EXAMINATION (Date of Assessment: September 19, 2011) (Time of Assessment: 1:00pm) GENERAL SURVEY Received patient lying

on bed, awake, conscious and coherent with an ongoing IVF of D5LRS regulated at 31-32 gtts/min, hooked at the right arm @ full level, patent and infusing well. The patient is mesomorph. He appears to be at her stated age. His sexual development is appropriate for age and development. He is oriented to person, date, time and place. Facial features are symmetric with movement. He maintains minimal eye contact and speaks softly. He appears weak and looks irritable at times. He also manifests guarding behavior and facial grimace. INITIAL VITAL SIGNS: BP=120/90mm Hg T=36.9C PR=88 bpm RR= 22 cpm AREA ASSESSED I. SKIN Color Moisture METHOD USED NORMAL FINDINGS ACTUAL FINDINGS CLINICAL ANALYSIS Normal Normal

Inspection Palpation

Light to dark brown

Light brown

Moisture in the skin folds and axilla (varies (+) Moisture in the skin folds and axilla with environmental temperature and humidity, body temperature and activity Feels smooth & firm with even surface Pinched-up skin returns immediately to original position. (1-2 secs) No edema No lesions Smooth and firm Skin returns immediately to original position when pinched. No edema (+) lesion in the lower abdomen

Texture

Inspection and Palpation Palpation Inspection and Palpation Inspection and Palpation

Normal

Mobility & turgor

Normal

Edema Lesions

Normal Due to surgical incision

Temperature

Inspection and Palpation

PHYSICAL EXAMINATION (Date of Assessment: September 19, 2011) (Time of Assessment: 1:00pm) Skin is normally warm in temperature Warm skin Normal

II. HAIR Color Amount and distribution

Inspection Inspection and Palpation

Black Equally distributed ,thick silky and resilient

Black Equally distributed ,thick silky and resilient None

Normal Normal

Presence of parasites III. SCALP Shape Texture Lesions

Inspection and Palpation

None

Normal

Inspection Inspection and Palpation Inspection and Palpation

Symmetrical and round Smooth, firm None

Symmetrical and round Smooth and firm None

Normal Normal Normal

IV. NECK Position Mobility

Inspection Inspection

Centrally located between the shoulders Can move spontaneously in all directions

Located centrally between shoulders Can move spontaneously in all directions

Normal Normal

V. EYES Eyebrows

Inspection

Hair evenly distributed, skin intact, move symmetrically, equal movement Skin intact without redness, no discharge, or lesions.

Evenly distributed and move symmetrically No redness, discharge and lesions

Normal

Eyelids

Inspection

Normal

Eyelashes Conjunctiva Sclera IRIS AND PUPIL Shape Color Symmetry Reaction to light

Inspection Inspection Inspection

PHYSICAL EXAMINATION (Date of Assessment: September 19, 2011) (Time of Assessment: 1:00pm) Equally distributed Evenly distributed Pink palpebral conjunctiva Sclera appears porcelain white Pink White

Normal Normal Normal

Inspection Inspection Inspection Inspection

Round Black Equal in size PERRLA

Round Black Equal in size Round, regular and equal size in both eyes

Normal Normal Normal Normal

VI. EARS Skin Condition

Inspection

Color same as facial skin, skin intact with no lumps or lesions Mobile, firm, not tender, pinna recoils after it is folded Symmetrical

Light brown in color, skin intact with no lumps or lesions

Normal

Texture, elasticity & areas of tenderness Symmetry

Inspection and Palpation Inspection

Pinna recoils after it is folded, firm and not Normal tender Symmetrical Normal

Inspection Position Lateral to the eyebrows and auricles in line with cantus of the eye Lateral to the eyebrows and auricles in line Normal with cantus of the eye

VII. NOSE Skin appearance

Inspection and Palpation Inspection

Color: Same as face Consistency: Smooth

Light brown color, smooth

Normal

Symmetry

PHYSICAL EXAMINATION (Date of Assessment: September 19, 2011) (Time of Assessment: 1:00pm) Symmetrical Symmetrical

Normal

VIII. Lips

MOUTH AND OROPHARYNX Inspection and Palpation Pink color, soft, moist, smooth Pink, moist and smooth Normal

Teeth and gums

Inspection White, shiny, tooth enamel Pink gums, moist, firm texture White teeth Pink gums, moist, firm texture Freely moving; centered roughened from papillae , no lesions Uvula is positioned in the midline Centrally located between the shoulders Can move spontaneously in all directions Normal

Tongue

Inspection Freely moving; centered roughened from papillae , no lesions Normal

Uvula IX. NECK Position Mobility

Inspection Uvula is positioned in the midline Inspection Centrally located between the shoulders Inspection Can move spontaneously in all directions Normal Normal Normal

X.

THORAX AND LUNGS Shape & configuration Chest expansion Breathing pattern

Inspection Inspection Inspection and Auscultation Auscultation

Thorax is symmetric, in an elliptical shape Full and symmetric chest expansion Quiet, rhythmic, and effortless

Symmetric Full and symmetric chest expansion Rapid shallow breathing RR= 22 cpm Absence of cardiac murmurs

Normal Normal Due to pain

Heart Sounds

Absence of cardiac murmurs

Normal

PHYSICAL EXAMINATION (Date of Assessment: September 19, 2011) (Time of Assessment: 1:00pm)

XI. BREAST Size, shape & contour

Inspection and Palpation

No tenderness, nodules, swelling and edema

No tenderness, nodules, swelling and edema

Normal

XII. ABDOMEN Abdominal contour Tenderness

Inspection Palpation

Flat or round No tenderness

Flat Presence of tenderness

Normal Due to trauma to nerve endings

Lesion

Inspection

(-) lesion

(+) lesion about 2-3 inches

Due to surgical incision

XIII.

UPPER EXTREMETIES

Skin Characteristics Inspection and palpation Normal racial skin tone; warm and equal Warm temperature; no edema, lesions and tenderness Light brown color Uniformity in color Equal Symmetrical Uniform color Symmetrical Symmetrical Normal

Palms Size(arms) Symmetry MUSCLE

Inspection Inspection Inspection

Normal Normal Normal

Size Muscle Strength ROM

Inspection Inspection Inspection

PHYSICAL EXAMINATION (Date of Assessment: September 19, 2011) (Time of Assessment: 1:00pm) Equal size on both sides of body Equal size on both sides of body Equal Strength on each body size Full ROM Equal Strength on each body size Full ROM (4/5)

Normal Normal Due to pain and body weakness

XIV. LOWER EXTREMETIES Skin Characteristics Inspection and palpation Normal racial skin tone; warm and equal Warm temperature; no edema, lesions and tenderness Light brown color Normal

Skin color Size(legs) Symmetry ROM

Inspection Inspection Inspection Inspection

Uniformity in color Equal Symmetrical FULL ROM

Uniform color Equal Symmetrical

Normal Normal Normal

3/5-active movement against gravity only and not against resistance

Due to pain

PHYSICAL EXAMINATION (Date of Assessment: September 19, 2011) (Time of Assessment: 1:00pm)