Physical examination for care plan and case presentation for nurses@nurses outlook


PHYSICAL EXAMINATION



GENERAL OBSERVATION

Constitution                                        :           Ectomorphic
Stature                                                :           Normal stature           
Posture                                                :           Normal posture, no deformity, normal gait
Personal appearance                           :           Neat and tidy.
Emotional status                                 :           Anxious and depressed.
Co-operativeness                                :         Co-operative

VITAL SIGNS

Temperature                                       :          98.60 F
Pulse                                       `           :          88 b/mt
Respiration                                         :          26 br/mt
BP                                                       :          130/90 mm of Hg

HEIGHT AND WEIGHT

Height                                                 :          45 Kg
Weight                                                            :          160 cms

SKIN AND MUCOUS MEMBRANE

Colour of the skin                               :           Pallor is present, no lesions or cracks.
Edema                                                 :           Absent
Moisture and turgor                           :           Skin is less moist.

HEAD

Shape                                                  :           Normocephalic, no lesions tenderness, hair                                                                         colour and distribution are normal, hair is                                                                            brittle, no dandruff or lice.
EYES

EXPRESSIONS                                  :           Normal, no discharge
Eyelids                                                 :           No edema, no blepheritis.
Eyeball                                                :           Normal and clear.
Conjunctiva                                        :           Pale
Sclera                                                  :           Creamy white in colour, no discolouration.
Iris                                                       :           Black in colour.
Visual acuity                                        :           Normal
Pupils PERRLA                                  :           Normal, symmetrical and normal pupil
                                                                        Constriction (3mm)
Eye movements                                  :           In conjugate fashion.

EARS

Appearance                                         :           Auricles are symmetric, wax is present.
Hearing                                               :           Normal             
         
NOSE                
                               
Appearance                                         :           No deviation of nasal septum or nasal                                                                                   flaring, mucous membrane is pale.
MOUTH AND THROAT

Lips                                                     :           Dry, no cracks
Tongue                                                :           No glossitis, reddish in colour.
Teeth                                                   :           Not stained, no missing teeth
Gum                                                    :           No bleeding or gingivitis.
Buccal mucossa                                  :           No stomatitis
Palate                                                  :           Intact, no deformity.
Taste                                                   :           Normal sensation of taste.

NECK

Appearance                                         :           No deformity, or stiffness.
Trachea                                               :           Centrally located
Lymph node                                        :           Not palpable.
Thyroid gland                                     :           Not enlarged

CHEST AND RESPIRATORY SYSTEM

INSPECTION
Symmetry                                           :           Bilaterally symmetrical
Expansion                                           :           Equal
Equality of movement                        :           Normal
Type of respiration                             :           Abdominothoracic
Rate
Rhythm                                               :           Normal

PALPATION
Expansion                                           :           Normal
Local Swelling                                   :           Absent
Vocal Tactile fremitus                                   :           Normal

PERCUSSION

Basal                                                   :           Normal
Apical                                                 :           Normal
Axillaries of mid zone                                   :           Normal

AUSCULATION

 Bronchial breath sounds                    :           Normal, high pitched and clear.
Broncho vesicular sounds                  :           Clear and relatively low pitched.
Vesicular sounds                                :            Normal and low pitched       

CARDIO VASCULAR SYSTEM

 INSPECTION

Chest contour                                     :           Normal, no sternal depression
Pericardium                                        :           Normal, no bulging
Neck                                                    :           Normal, no jugular venous distention.

PALPATION

Pericardium                                        :           No thrill
Neck                                                    :          Arterial pulsation is present.
Supra sternal notch                             :           No thrill

PERCUSSION

Cardiac outline                                   :           Difficult to find the cardiac border.

AUSCULTATION

Apical rate                                          :           S1, S2 heard, no murmur.
BP                                                       :           130/90 mm of Hg
Neck                                                    :          No carotid bruits or murmurs
ABDOMEN

INSPECTION

Shape                                                  :           Normal, scaphoid shape
Movements                                         :           Normal, abdominal wall bulges during                                                                                                         inspiration and falls on expiration.
Skin texture                                        :           Normal, decreased skin turgor, no cyanosis                                                                         or lesions.
Contour                                               :           Normal flat, no mass
Normal                                                :           Normal peristaltic sound
PALPATION

Mass                                                   :           Absent

PERCUSSION                                     :           No fluid or gas collection

AUSCULTATION                                :           Normal peristaltic sounds
BACK

Spinal curvature                                 :           No deformity, concavity in cervical lumbar                                                                                      region and convexity in the thorax.
Symmetry                                           :           Normal
Movement and mobility                     :           Normal movements
Tenderness                                          :           Absent

GENITALIA                                      :           Nothing significant.

UPPER AND LOWER EXTREMITIES

Upper extremities                               :           Normal ROM, no deformities.
Lower extremities                              :           Normal ROM, no deformities.

NERVOUS FUNCTION           

Higher function                                  :           Normal
Speech                                                :           Clear and fluent
Cranial nerves                                    :           Normal.
Motor function                                   :           Normal, good muscle tone.
Sensory function                                :           Normal, responds to pain and touch.

Reflexes                                              :           Normal