PHYSICAL ASSESSMENT REPORT
Student Name Meshal Faleh Albalawi
Student ID
Date October 16, 2022
Hospital
Instructor Name
Patient’s Name
Healthcare Record Number
(HRN)
Age
Gender
Presenting Chief Complain
Triage Category
Infection Status
Accompanied by
Source of Data Collection
Medical Diagnosis
Last Oral Intake
Last Medication Intake
Allergies / Hypersensitivity
Past Medical History
Past Surgical History
Immunization Status
Family History
Patient’s Data
Mohammed Khalid Alanzi
22 years old
Male
Patient complaints of plaque-like rash and joint
pain for 2 weeks already. He reports that he first
noticed the rash on his knees and has now
developed on his elbows and scalp. He also
reports that the rash is sore and slightly itchy.
He reports that a stressful situation exacerbates
his skin issue. He reports that the severity of his
rash and joint pain is 6/10.
Urgent (Yellow)
Unknown
Parents
Patient
Psoriasis
1 hours ago
Over-the-counter Ibuprofen 400 mg PO, q6H,
PRN
No known drugs or food allergies
Varicella & tonsilitis
None
His immunizations are up to date, especially the
CoViD-19 vaccines. He just received his flu
vaccine last year.
Hypertension, Psoriasis, Multiple Allergies, &
 Eczema
Personal / Social History Patient denies smoking, alcohol, & drug use.
Current / Pre-Existing Unknown
Disease

Head-to-Toe Assessment (Review of Systems)

General
 No signs of fatigue
 No fever, chills, or night sweats
 No significant weight changes
 Well-nourished and groomed
 Normal gait
 Appears uncomfortable
Skin/ Mucous Membranes/ Nails
 Negative from pigment changes
 No other rashes or cyanosis
 Positive for sore, pruritic, silvery scales, polycyclic salmon-colored
plaques located on the scalp, elbows, and knees bilaterally with discrete
borders
 Plaques are approximately 1cm or more in size
 Sore and slightly painful to palpation
 Presence of nail pitting and onycholysis.
Head, Eyes, Ears, Nose, Throat
 No changes in vision and hearing
 Negative for blurred or doubled vision, tinnitus, and discharge from ears
 Negative for vertigo, nosebleeds, and nasal secretions
 Negative for sore throat, bleeding gums, mouth ulcers, and tooth problems
 Oropharynx is clear with no redness or swelling
Musculoskeletal
 Symmetric muscle and bone development
 Positive for diffuse joint pain
 Negative history for gout, arthritis, trauma, or fractures
 Mild swelling of knees, wrist, and ankles joints bilaterally with present
pain
Psychiatric
 Positive for sleep disturbances, stress, and socialization issues
 No history of anxiety and depression
 Denies any suicidal thoughts
 Skin Assessment
Inspection
Color Slightly fair skin
Thickness Normal skin thickness
Symmetry Symmetrical, bilateral skin distribution
Bruises, Scars, Wounds, Presence of some scratches and wounds near the
Scratches, or Unusual location of the lesions
Marks
Presence of Skin Lesions
 Primary Lesions Plaques
 Secondary Lesions Scales
 Location & Extensor Distribution (elbows & knees)
distribution 1cm or more
 Size Salmon-colored plaques and silvery scales
Slightly elevated, palpable
 Color
No mass and fluid content
 Elevation & depth
Discrete borders
 Content Slightly thick lesions
 Border Bilateral skin lesions
 Thickness
 Symmetry
Integrity Presence of salmon-colored plaques, no other
skin breakdown
Edema No edema found
Pigmented lesions No visible pigmented lesions
Palpation
Moisture The skin lesion is slightly moist
Temperature The skin is slightly warm to touch
Texture The skin slightly smooth
Turgor Normal skin turgor
Mobility Normal skin mobility
Edema No edema found
Consistency Firm skin
Presence of Lesions
 Moisture The lesion is dry
 Crust Present
 Texture Rough
Slightly elevated, palpable
  Elevation & Depth Slightly warm
 Temperature Present
 Thickness Present
 Tenderness

Nail Assessment
Inspection
Nail Surface Slightly convex with the presence of pitting and
onycholysis
Posterior and Lateral Nail Separation of nails to its nail bed due to
Folds onycholysis
Nail Edges Long nail edges
Hygiene Clean fingernails
Color Slightly yellowish due to onycholysis
Consistency Nails are slightly thick with the presence of
onycholysis
Nail Base Angle 160 or less
Capillary Refill 1-2 seconds
Palpation
Texture The texture is slightly curve with pitting
Firmness The nails are firm due to its thickness
Thickness The nails are slightly thick with pitting
Adherence to Nailbed Separation of nails to nail beds

Hair & Scalp Assessment

Inspection & Palpation
Color Black hair with silvery scales
Distribution Equal distribution but there are some plaque
patches
Quantity Normal hair thickness with numerous plaques
Hygiene Well-groomed and clean
Texture Hair & scalp texture are normal
Presence of Scalp Lesions Scalp Psoriasis with plaques and scales

Vital Signs
 BP- 115/ 76 mmHg (right arm, sitting position)
 PR- 82 bpm (regular)
 RR- 17 cpm (non-labored)
 Temperature- 36.8 C (Oral)
 Pain- 6/10
 Height- 175 cm.
 Weight- 82 kgs.
Diagnostics / Laboratory Test Results
 WBC- 8,000
 Skin Biopsy- Negative for fungal infection, Positive for psoriasis
Diagnosis
 Primary- Plaque Psoriasis / Psoriasis Vulgaris
 Differential- Eczema, Lichen Planus, Mycosis Fungoides