Physical Assessment

Date/Time of assessment: October 4, 2023, 1:30 pm

Head-to-toe Inspection Palpation Percussion Auscultatio Interpretatio
inspection n n of
abnormaliti
es

Skin, Hair,

and Nails - Evenly

-The skin is -Minimal
colored skin
SKIN smooth and scars of p-
tones
even atient T on
without
his right
- The skin is
unusual
elbow and
normally in
discoloration
right knee
thickness
s
due to
- No lesions
motorcycle
palpated and
- Absence of
accident as
seen.
body odor
stated by the
- Skin is
- Lighter
patient.
warm in
colored
temperature. -According
palms, soles,
to Cleveland
and pinkish
Clinic
lips - Normal
(2022),
- Tattoo on skin
bluish
his right elasticity
discoloration
hand was
occurs when
noted.
your blood
- Minimal old
 scar on his lacks the

riight elbow oxygen it

and right needs to

knee. reach the

- The skin in different

his abdomen tissues in

is evenly your body

colored

- The skin is

intact, with

no reddened

areas no

bruises was

noted.

- Absence of

body odor.

HAIR - Hair color - Head is

is black and non-tender

thin. and no mass

- Hair is long felt upon

palpation.
and the

length is 3
inches.

- Hair is

shiny,

smooth but

with a

presence of

slight

dandruff but

does not

cover the

entire scalp

only the

small portion

in the front

and temporal

part, wavy,

and oily but

with the

presence of

dandruff

- Scalp is dry

and with the

presence of
 dandruff at

the front

part/

- Hair is

evenly

distributed

NAILS -Nails are - Nails are -pale nails

trimmed and hard may indicate

clean - Nails are liver disease,

- The nail attached to diabetes,

is pale in nail bed congestive

color and no - Pale pink heart failure

vertical tone returns or lack

ridges are with a nutrients in

noted. capillary refill diet.

of 2 (WebMD,
- No Nail
seconds. 2022)
clubbing is

noted in both

hands.

-presence of

nail polish in

the toenails
 is observed.

Head and - The head is -No bruits

Neck
hard and upon
HEAD - The head is
smooth auscultation.
symmetrical,
without
heart
lesions
shaped, and
- The
in the
temporal
midline of
artery is non-
the body
tender
size
- Tempoman
NECK -The head is
dibular
held still and
joint is not
upright
swelling,
- The face is
tenderness,
symmetric
or crepitation
and heart
with
shaped with
movement.
no abnormal

movements -Trachea is

noted. midline

- No

enlargement
- The neck is
or
 symmetric tenderness

without is present in

bulging the neck

masses.

- The thyroid

cartilage and

cricoid

cartilage

move

upward

symmetricall

y as the

client

swallows

-Vertebrae

are not

visible

- Neck

movement is

smooth

EYES - The eye - No

movement is tenderness

smooth in the
throughout auricle,

all six tragus, and

directions mastoid

-The upper process.

and - No lumps

lower eyelid or nodules

close easily

and meet

completely

when closed

- No lesions

and redness

on both

eyelids.

- Eyeballs

are

symmetricall

y aligned

without protr

uding

- Bulbar

conjunctiva

is clear moist
 and smooth.

- The sclera

of the eye

is white.

-The lower

and upper

palpebral

conjunctiva

are free from

lesions.

-Pupil is

round with

regular

border

● Iris is

round

and evenl

y colored

● Normal

Pupillary

response

Mouth and -Lips - No masses

throat
are pinkish or lesions in
 in appearanc the mouth.

e and moist.

-Three of his

wisdom

teeth are

absent both

up and down

areas.

- Gums are

light pink in

color.

- Tongue is

light pink

and has no

lesions

- Throat is

pink without

lesion

-Tonsils is

present with

pinkish color

Thorax and -chest pain

Lungs was noted.

 Pain scale of

5 out of 10

-shoulders

are equal

horizontal

position

-The client

does not use

accessory

muscle to

assist

breathing.

-Client lying

on bed,

breathing

normally with

arms at side.

Respiratory - Respiratory

rate: 21 cpm

Cardiovasc - Blood - Pulse: 55 -People with

ular
Pressure:13 bpm heart failure,

0/80 mmHg has a

considerable
possibility to

have high

blood

pressure,

often known

as

"hypertensio

n."

Approximatel

y two-thirds

of people

whose

hearts can't

pump

enough

blood due to

the ailment

have high

blood

pressure

now or

previously

did.
Hypertensio

n is a major

risk factor for

heart failure

(WebMD,

2022).

-People with

heart failure,

has a

considerable

possibility to

have high

blood

pressure,

often known

as

"hypertensio

n."

Approximatel

y two-thirds

of people

whose

hearts can't
pump

enough

blood due to

the ailment

have high

blood

pressure

now or

previously

did.

Hypertensio

n is a major

risk factor for

heart failure

(WebMD,

2022).

-Patient T

has

Congestive

Heart

Failure,

which

causes
blood

vessels in

the heart to

narrow or

blocked,

reducing

blood supply

to the heart

muscle and

causing the

heart to work

harder to

compensate

for the

weakening

heart

muscle,

which can

lead to

angina.

-Patient T

has

bradycardia
 due to

Congestive

heart failure

which heart

cannot pump

enough

blood.

Gastrointes
tinal

Circulatory September

302023

Hemoglob

in: 168

mmol/L

Genitourina - Urine color:

ry
Yellow

- Defecates

1 time

everyday.

well-formed
 Yellow stool

Reproductiv
e

Neurologica - Eyelids
l
blink

bilaterally

- The client

hears a

whisper in

both ears

- tongue

movement is

symmetrical

-gait is

steady

Musculoske -Client is

letal able to stand

and walk but

with

assistance.

-Can move

the head and

neck easily.

-can easily

open and

close the

mouth