Physical Examination

General appearance:
Conscious
Saggy skin
Unable to move by herself
O2 nasal Cannula therapy
IVF: PNSSREgulated at 20 gtts/min
Slurred speech
Moaning
Vital signs taken
Temp 37.6
PR 100
RR 24
Blood pressure 140/90

Site of assesment Findings

nd
Skin 2 degree lesion 8-10 in diameter
Dark red color
Scar in the abdomen (ceasarian)
Dryness and cracked of soles

Head Normocephalic
Black and white hair
No presence of dandruff

Eyes Sluggish reactionto light

Conjunctiva pinkish
Sclera are white
CN III, IV ,VI are intact
Can’t read Snellen chart

Ears Pear shape

Hearing acuity is diminished,needs to shout to be
heard

Mouth Lips are dry

Gums is pinkish
Tonsils are not inflamed

Neck No swollen lymph nodes

Unable to move her neck to the right side
No bruit on carotid artery
Thyroid not swollen
Trachea on the middle

chest and lungs

Chest has no iverted nipple
No discharges
Lymph nodes arenot palpable
 Left and right chest are equal I expansion
Postitive crackles in on both lung fields
No rashes and palpable masses
Tactile fremitus is palpable
S1 and S2 are audible

Abdomen Symmetrical
Uniform in pigmentation
Scar in Umbilicus to Symphysis pubis (ceasarian)
RLQ-12bpm RUQ-10bpm LUQ-10bpm LLQ-10bpm
No hepatomegaly
No spleenomegaly

Genitalia/anus Labias are not inflamed

Distribution of pubic hair is inverted triangle
No abnormal discharge
No foul smell
Anus is not perforated.

Upper extremities
IVf insersted at right metacarpal
Fingernails with capillary refiil of 2 sec.
Cracked palms

Lower extremeties No deformities

No rashes
Cracked soles 2nd degree lesion
In the right metatarsal with no pus and no foul
odor

Grade of body part movement

RU 4/5
LU 4/5
RL 2/5
LL 4/5

Verbal tactile pain

Concious - - +
lethargic + + -
stuporous - - +
Semi coma - - +
comatose - - -