PHYSICAL ASSESSMENT

Integumentary System Skin color varies according to racial and genetic makeup. Brown depending on the clients basic skin color. Oral mucosa is dry, pale, skin warm, intact with good turgor. Smooth and elastic, warm and dry. Feels touch, sensitive to heat and cold pressure. No lesions present. Hair evenly distributed. Texture dependent on racial and genetic makeup. Nails pink and firm. Color return within 2 seconds. Head and Neck Wide, normocephalic, symmetrical and contour rounded. Smooth with no unexpected contours or bulges. No discharges noted. Palpebral fissure and nasolabial folds present, symmetrical. Facial shape is oval. Can move facial muscles, no involuntary muscle movements, intact. Neck is in midline, no lumps and bulges noted. Full ROM. Non tender, no jugular venous distension. Eyes Eyelids equal to movement. Both pupils constrict. No opacity noted. The shape of pupils is round and midposition. Responds to blink reflex. Peripheral vision intact in both eyes. No swelling and redness noted. No external lesions. Ears Auditory changes due to aging. No external lesions noted. Non tender when palpated. No discharges. Dry cerumen, yellowish in color. Canal patent. Nose and Sinus Symmetric and straight; no discharge or flaring; uniform in color. Non tender. Air moves freely as client breathes through the nares. Mucosa pink, clear, watery discharge, no lesions noted. Nasal septum between nasal chambers are intact and in midline. Non tender when palpated.

Mouth and Oropharynx The lips is pale in color, dry, soft, smooth, and ability to pursed lips. The buccal mucosa is pale in color, dry, smooth, soft. He had 14 adult teeth, white, shiny tooth enamel, pale gums. No retraction of gums (pulling away from teeth). Tongue is central position. Pale in color, moist, slightly rough, no lesions noted. Moves freely, non tender. The uvula is position in midline, pink in color, smooth. Oropharynx and tonsils are pink in color, smooth. No discharge. Thorax and Lungs Increased respiratory rate due to trauma of chest wall. Crackles (rales) may heard upon auscultation due to sudden opening of dosed airways.

Breast Unequal in shape, symmetrical. Skin color lighter in exposed areas; no lesion, redness or edema; texture is even. Nipples everted, pointing in the same direction, no lesion, no discharge. Areola and nipple darker than breast tissue. Abdomen Skin color in consistent with patients ethnicity. Color is lighter on the abdomen than any other areas of the body because of lack of sun exposure. Skin the same throughout the abdomen. Abdominal skin is intact without lesion or masses. No change of color around umbilicus. Genitourinary- Reproductive System Triangular, sparsely distributed on scrotum and inner thigh, absent on penis. No lesion noted. Non tender when palpated. Inguinal lymph node is palpable and non tender. No masses or lumps upon palpations. No redness nor swelling around or in genitalia. No discharges.

Anus and Rectum The color is the same as the other part of the body and appears normal size and texture. No swelling. No rashes and lesions noted. No form of redness in the skin of the anus and rectum. Musculoskeletal System Has no weight bearing capacity and easily breaks down in the absence of locomotion. Not symmetrically bilateral. Has no support on the weight of the head. Has no center of mass of body and generally falls easily without the support of the other extremities. Neurologic System Mood appropriate to situation, responds to normal command. Answers questions appropriately. Oriented to time, person, place, and purpose. Recent and remote memory intact. Eyes open, squeeze fingers, move extremities. Responds to stimuli by reaching out or trying to stop pressure. Can recognize common objects. Can distinguish two point stimulus. Can readily determine the position of the fingers.