Health Assessment:

Head: Fine distribution of hair, no presence of edema or lesions Neck: (-) palpable lymph nodes Ears: (-) Discharge Nose: (-) Lesions and discharge; Symmetric. Mouth: (-) Lesions, pink Shoulder: Symmetric, Chest/Breast: Presence of Abscess on Right Breast, 20X23cm Lungs: (-) wheezing, clear breath sounds Cardiovascular: (-) murmurs Musculoskeletal: No lesions Abdomen: Flabby, soft abdomen Genito-uro: No data Rectum: No data

II.

Physical Assessment

GENERAL APPEARANCE: Conscious and awake HEENT Head: Configuration- normocephalic Hair- normal texture, fine and even distribution of hair Scalp- lesions, tenderness Eyes: Sclera- white Conjunctiva- pale Ears: External Ear-lesions, masses, tenderness Auditory Canal- normal Nose: Color- pink, no discharge Throat and Mouth: Teeth: Present and in good dentition Tongue: (-) lesions NECK Active ROM: normal flexion, extension, lateral rotation and tilting Trachea: in midline Thyroid: no palpable Lymph nodes BREASTS (+) redness, erythematuous, Presence of Abscess on Right Breast, 20X23cm, tender to touch, HEART Murmurs: Negative for Murmurs THORAX & BACK LUNGS o clear, normal vesicular breath sounds ABDOMEN o Flabby, soft abdomen EXTREMITIES o (-) Presence of Cyanosis, Pallor o (-) cyanosis, clubbing o Palms- normal in color, texture o Muscles- normal in size NEUROLOGIC o Mental Status: Awake & Alert; oriented to person, place & time o Cranial Nerves: o II: Visual Acuity- 20/20 with pocket screener, both eyes ,Visual Fieldsintact in all fields o II and III: Positive and Normal for PERRLA (Pupils, Equal, Round, Reactive to Light and Accommodation) o III, IV, VI: EOM- intact o V: Light Touch Face- normal in all 3 divisions of V o VII: Wrinkle Forehead, Close Eyes, Show Teeth- normal o VIII: Hearing- normal o X: Cough- normal o XI: Shrug Shoulders and check sternocleidomastoid muscles normal and symmetrical

o XII: Protrude Tongue- midline protrusions Sensory: Light Touch- normal Reflexes: Deep tendon Coordination: Gait and Balance- normal Finger to Nose- normal

GYNECOLOGIC EXAM - No data