SHERYL ANN B.

PEDINES
BSN-IV

PHYSICAL ASSESSMENT

General Appearance: Mr. Yu is 55 years old, lying on his bed and awake. His look is congruent to his
actual age. He appears pale, restlessness, coherent, and conversant. He dressed up appropriately with
the situation but not properly well groomed. His hair is messy. He communicates with maintained eye
contact with expressions appropriately suited with the situation. He was conscious and well oriented.
Overall health state was weak.

Vital Signs:
 T= 37.3 C,
 PR= 77 bpm,
 RR= 18
 CR= 79 bpm,
 BP= 130/90 mmHg.

SKIN

 brown in color, rough, dry, and warm.

 has good skin turgor.
 Brownish discolorations that resemble freckles are observed on arms and face.

HEENT

Head

 Skull is round in shape, symmetrical (normocephalic).

 No masses noted.
 Facial movement is symmetrical.
 Hair is dry in texture; its color is black with minimal streaks of gray.
 Scalp is clear from dandruff and lice.
 No scars and wounds noted.

Eyes

 Has symmetrical eyebrows movement, shape and hair distribution.

 Eyebrows have same color with hair.
 Eyelashes are evenly distributed and curled outward.
 Eyelids have no discharges and bilaterally blink.
 Upper lid covers the small portion of the iris and cornea.
 Lacrimal duct openings (puncta) are evident at nasal ends of upper and lower lid with no
tenderness noted.
 Palpebral conjunctiva are pinkish in color while the pupils constricted to light (2mm), round
in shape, isochoric, shows uniform convergence.
 Able to rotate eyes and has coordinated eye movements.
SHERYL ANN B. PEDINES
BSN-IV

Ears

 Auricle has same color with the skin, has symmetrical shape and located a little bit higher
than the eye.
 Pinnas are symmetrical, mobile, and able to recoil, with no lesions noted.
 Able to hear on both ears. Her ears’ lobules have holes for jewelry.
Nose

 Nose has uniform color and symmetrical in shape.

 Nasal hairs are very evident when light is flashed through the nasal passageways; its color is
black.
 No nasal flaring
 Both nares are patent, air moves freely as client breathes through the nares upon observed
respiration. Nasal septum is straight and in midline.
 Nasal mucosa is pinkish in color, has no discharges and no lesions.
 No tenderness of sinuses noted.
Throat and Mouth
 lips are dry and pale.
 no dysphagia or ulcerations noted on oral cavity.
Pharynx

 Uvula is found well placed in midline of soft palate.

 Mucosa is pinkish in color.
 Tonsils are not inflamed.
Neck

 Trachea is in midline.
 No tenderness of thyroid noted.
 No enlargement of the neck noted.
 Able to flex and extend neck and move it laterally (L and R).

Lungs
 normal resonant percussion
 with clear sounds
 normal vesicular breath sounds
 difficulty of breathing.
Heart
 no bruits
 no murmurs
Extremities

 Peripheral pulses are symmetrical and regular.

 Nails are long and untrimmed, pinkish in color, and have a capillary refill time of 2 sec. after
blanching.
 no clubbing of fingernails was noted.
 Calluses were observed at the tip of her fingers and toes.
 Muscle strength is equal on both sides of the upper and lower extremities.
SHERYL ANN B. PEDINES
BSN-IV

 with pedal edema

Abdomen

 Abdomen’s color is same with the rest of the part of the body.
 Umbilicus is coated with blackish dirt.
 with ascites
Neurologic Assessment

Cranial Nerves:

 (CN1) able to identify aromas by smelling with eyes closed.

 (CN2) able to see objects.
 (CN3) pupil constricted to light sensation.
 (CN4&6) able to move eyeball downward and laterally.
 (CN5) able to blink eyes.
 (CN7) able to smile, raise eyebrows, puff cheeks and close eyes.
 (CN8) able to respond to questions being heard.
 (CN10) has rough and vibrating sound.
 (CN11) able to shrug shoulders, elevate and flex arms and legs against resistance.
 (CN12) able to protrude tongue and move it side to side.