SYSTEM PHYSICAL ASSESMENT

INTEGUMENTARY Pt.’s skin was warm to touch with poor skin turgor. Pallor was
not noted. Pt. was able to feel sensation.

Head is symmetrical upon inspection. Head is proportionate to

HEAD AND FACE her body with normal facial feautures. Pt.’s hair is evenly
distributed. Dryness of the hair not noted. No lesions and
tenderness noted. Pt. has no history of accidental head injury.
Pt.was able to smile and frown. Pt.was able to blown out cheeks.
Pt.was able to raise her eyebrows. Pt.was able to feel sensation
upon touching her forehead, cheeks and chin. No abrasions and
lesions on her face was noted.

Eyes are symmetrical upon inspection. Pt. has black eyes.

EYES
Eyelashes and eyebrows are equally but finely distributed on
both sides of the face. Pupils are equal, round, reactive to light.
both left and right. No unusual discharges from the lacrimal
ducts noted upon palpation. Pt. can able to recognize size,
shape and colors correctly.

Ears are symmetrical upon inspection with upper attachment at

EARS
level of the eyes corner (lateral canthus). Pinna and external
canals are intact upon inspection. Pt.reported she has no history
of ear pain, ringing in the ear, or ear infections.

Nose is symmetrical with good septal deviation noted upon

NOSE inspection. No lesions or scars noted. Nasal mucosa is red with
adequate nasal hair and accumulated mucos secretions upon
inspection. Client is able to smell pleasant and foul odors
suggesting good olfaction.

MOUTH Pt.’s lips has no presence of lesion upon inspection. Palor is

noted. Pt. was able to close mouth. No inflammation of tonsils
noted. Tongue is normal in color with moisture. No lesions noted
upon inspection.

Neck muscles are symmetrical upon inspection. Skin on the neck

NECK is intact with poor integrity. Neck lymph nodes are not swollen
upon palpation. Carotid pulse is palpable. Trachea is at the center
and immovable upon palpation. No masses and lesions noted.
 RESPIRATORY SYSTEM RR of 21 cycles per minute, regular in rhythm, with noted
exertion and use of accessory muscle upon inspection. Frequent
coughing accompanied by expectoration of thick-yellowish
phlegm in moderate amount noted upon entire duration
assessment. Crackles heard upon percussion of the anterior and
posterior of the chest. O2 is attached

CARDIOVASCULAR SYSTEM No heart murmurs heard during auscultation. Regular rhythm

with a pulse rate of ranging from 65-76 bpm. Pt.’s blood pressure
was normal in range.
BREAST Pt. stated her breasts are equally symmetrical. No tenderness
noted upon palpation. No unusual discharges reported. Lymph
nodes on the axilla are not swollen upon palpation. She has no
family history of breast carcinomas on both paternal and
maternal sides.

Pt. has report of muscle weakness as evidenced by limited

MUSCULOSKELETAL SYSTEM movement. Pt. needs assistance when turning side to side. Pt. can
slightly raise and move her upper and lower extremities.

Pt. has no complaints of nausea and vomiting. Abdomen is

GASTROINTESTINAL SYSTEM
globular upon inspection. Skin integrity in the abdomen in intact
with no lesions noted.

URINARY SYSTEM Pt. was wearing adult diaper upon assessment. Pt. was able to
void with 500ml of urine after weighing the diaper. No reports
of UTI. No complaints of unusual discharges. Pt. stated she can
able to pass flatus and defecate.

Upon assessment, Pt. was weak when laying down with head of
NEUROLOGICAL SYSTEM
bed elevated. Speech was clear. Pt. was oriented to time, place,
and person. But admitted she can no longer remember some
events in her life. Pt. was cooperative during assessment. She
responded appropriately to my questions.