PHYSICAL EXAMINATION

A. General Appearance
Client’s height and weight was not obtained. Body build is small frame and
posture is upright. Body movements and gait was not observed since the client
doesn’t want to walk. Odor is not good. There is an obvious physical deformity
specifically in her right rib where she had her thoracentesis and thoracotomy.
However, there are no signs of client abuse.

B. Mental Status
Patient is conscious during the assessment, she is oriented to time, place and
person. Her emotional status is pleasant and cooperative. She uses simple words
when answering our questions.

C. Skin and Nails

Skin is smooth, soft and dry. It is warm to touch. Hair is evenly distributed.
There is a good skin turgor and there is no edema present. A lesion is present on
client’s right chest with a size of 5-cents coin, client has no stretch marks. Nails are
concave and long with a smooth texture and a capillary refill of less than 3 seconds.

D. Head and Neck

No tenderness on scalp upon palpation. Scalp is white and hair is black, thick,
shiny, smooth and evenly distributed with no presence of parasites. Neck’s
movement is smooth and controlled from an upright position. It can be flexed,
extended, abducted laterally and be rotated. Neck muscle strength is 5/5. Trachea is
in the midline and thyroid is not palpable and so are the lymph nodes. Lymph nodes
are palpable associated with fever. Trachea is in the midline.

E. Eyes
Client has a 20/20 vision on snellen’s chart. Lid margins are moist and pink
and lashes are long, thick and curled outward. Eyes are blinking symmetrically.
Sclera is white and eyeballs are symmetrical. Conjunctiva is pinkish. Pupil is Black.
Pupil size is 3mm and it is equally round and reactive to light and accommodation.
When looking straight ahead, client can see objects in the periphery. Both eyes can
do the 6 extra-ocular movements in a smooth and coordinated manner.

F. Ears
 Ears are symmetrical. Auricle’s color is same as the facial skin and aligned
with outer cathus of the eye, about 10º from vertical. Ears are mobile, firm and not
tender; pinna recoils after it is folded. Ears have dry cerumen. Normal voice tones
are not audible. Client is always requesting to repeat words and statements. She is
able to hear ticking in both ears. Weber’s test was performed. Sound was heard in
both ears. Rinne’s test was performed. Air conducted hearing is greater than bone-
conducted hearing.

G. Nose
Nose is symmetric and straight. There is no discharge or flaring uniform in
color. Nose is not tender and no lesions are noted. Air moves freely as the client
breathes through the nares. Mucosa is pink and no lesions. Nasal septum is intact
and is in the midline. Maxillary and frontal sinuses are not tender.

H. Mouth and Pharynx

Lips are pallor and dry. Client was able to purse her lips. Mucosa is moist,
smooth, soft and elastic texture. Client has missing teeth she has 28 teeth and there
is brown discoloration of the enamel. Gums are pink and moist.

I. Breast and Axillae

Client refused to examine her breast.
J. Chest and Lungs
Equal chest symmetry, APL ratio is 2:1. Chest is symmetric. Spine vertically
aligned. Spinal column is straight, right and left shoulders and hips are at same
height. Skin in posterior thorax is intact. Chest wall is intact, no tenderness and no
masses. Chest expansion is symmetric. Client has quiet, rhythmic and effortless
respirations. Chest has full symmetric excursion. Vocal fremitus was normal.

K. Heart
Precordial area is flat. Point of maximal impulse is found on the 5th
intercoastal space midclavicular line. S1 heart sound is heard at the apex and S2
sound is heard at the base. Upon auscultation, the aortic area can be heard on the
right 2nd ICS, the pulmonic area on the left 2nd ICS, the tricuspid on the left 5th ICS
and mitral area on the 5th ICS left of midclavicular line. Carotid artery has full
pulsation. Jugular veins are not visible.
L. Abdomen
Abdomen is uniform in skin color. Abdomen is flat and round. There is no
evidence of enlargement of liver or spleen. Abdomen has symmetric contour.
Abdomen has audible bowel sounds. Tympany was heard over the stomach.
Dullness was heard over the liver and spleen. There is no tenderness. Liver is not
palpable.
M. Genitalia
Client refused to examine the genitalia.

N. Back and extremities

Peripheral pulses such as radial and brachial pulses are strong and warm to
touch. Pulse rate is 84 bpm. Muscles strength is 4/5. No pain during dorsiflexion.