V.

PHYSICAL ASSESSMENT

General Appearance:
Appears restless, irritable, and disheveled. Easily cries when approached. Has strong
tenseness and rigid movement. Does not follow through with directives. Does not observe eye
contact.
Presence of four point restraints on right and left hands and right and left feet, attached
to bed frame.

A. Integumentary System
Skin is brown in color. It is soft and warm to touch. When pinched at the abdomen, it
returned in one second, which indicated good turgor. Reddish, dry, scattered lesions on right
forearm, approximately 2 cm. in diameter. Wound with pus draining on right ankle of 2 cm. in
diameter and 1 mm. in depth.
Moderate dandruff noted on hair, as well as lice and nit infestations.
Nails are not well-trimmed and cleaned. Nail beds are pink and firm. No clubbing or
beau lines.

Neurologic System / EENT

Conjunctivae are pale. Anicteric sclerae without increased vascularity. Irises uniformly
black in color. Nares patent. Nasal septum is at midline.

PATIENT’S
CRANIAL NERVE HOW ILICITED NORMAL RESPONSE
RESPONSE
Cologne will be held under one
nostril with the other occluded
I Identifies scent correctly
while the client is closing her Not assessed.
OLFACTORY with each nostril.
eyes. Repeat with the other
nostril.
Newspaper or nameplate will
II Reads clearly, without
be held 14 inches away from Not assessed.
OPTIC difficulty.
the eyes.
Ask client to look straight
Pupils equally round and Pupils constrict
III ahead and approach each eye
reactive to light and upon illumination of
OCULOMOTOR from the client’s side with a
accommodation. penlight.
penlight.
Ask client to look straight
Uncovered eye does not
IV ahead, covering one eye with a
move as opposite eye is Not assessed.
TROCHLEAR cover card and observe
covered.
uncovered eye for movement.
With closed eyes, touch
forehead, cheeks and chin Identifies light touch,
V
with the tip of cotton dull, and sharp PRESENT
TRIGEMINAL
applicator and broken stem of sensations.
cotton applicator.
 Ask client to follow examiner’s Both eyes move in a
VI
finger as it moved in six smooth, coordinated PRESENT
ABDUCENS
cardinal fields. manner in all directions.
Ask client to smile, frown, Follows instructions
No facial anomalies.
purse lips, blow out cheeks, accurately.
VII
and raise eyebrows.
FACIAL
Able to discern sweet
Not assessed.
Let patient taste sugar. taste.
VIII Whisper a word 1 foot behind Able to repeat the
PRESENT
ACOUSTIC the client. whispered word.
IX Touch back of tongue with Brisk response as if to
GLOSSOPHARYNGEA tongue depressor to test for expel tongue depressor Gag reflex present.
L gag reflex. from mouth.
X Ask client to open mouth and Uvula elevates upon
PRESENT
VAGUS say “ah”. phonation.
Symmetrical, strong
Ask client to shrug shoulders contraction of trapezius
XI against examiner’s hands. muscles.
Able to turn head to
SPINAL Strong contraction of
sides against hand.
ACCESSORY Ask client to turn head against sternocleidomastoid
examiner’s hand. muscle on opposite side
that head is turned.
Symmetrical tongue
Ask client to protrude tongue
XII with smooth outward
and move it to each side PRESENT
HYPOGLOSSAL movement and bilateral
against tongue depressor.
strength.

B. Respiratory System
Respiratory patterns are even and unlabored. No use of accessory muscles upon
respiration. Deep inhalation and shallow expiration. Usual respiratory rate is 20 breaths per minute.
Clear breath sounds ascultated on all lung fields.

C. Cardiovascular / Circulatory System

Apical of 76 beats per minute. Palpable right and left radial and posterior tibi al pulses. It
is not thready nor bounding. Regular in rhythm. Clear, brief heart sounds throughout. No murmurs.

D. Genito – urinary System

Pubic hair sparsely distributed. Voids freely to a clear, yellowish urine with an amount of
400 cc per diaper. Consumes 3 diapers per day.

E. Gastrointestinal System
Canker sore of approximately 2 cm. on lower lip. Buccal mucosa is pink and dry. Pinkish
gums. Papillae present on tongue and midline fissure present. Abdomen is flat. Umbilicus is midline.

F. Reproductive System
 Breasts are bilaterally symmetrical. Areolae are light brown. No discharges on both
nipples.

G. Endocrine System
No swelling and tenderness of thyroid gland. No excessive sweating. Equal body hair
distribution.

H. Musculoskeletal System
Full ROM of the arms and legs. Hand grip is strong. Brief voluntary muscular jerking of
both extremities. Generalized tensed movements.

I. Lymphatic System
Thyroid and cervical lymph nodes are not assessed. No presence of swelling. Neck is
symmetrical and can rotate freely.

J. Hematopoietic System
Capillary refill of 1 second. No bruising.