Ashd Phys Ass

8/12/2019 Ashd Phys Ass

1/10

V. PHYSICAL ASSESSMENT

Vital Signs: BP 130/70mmHg

PR 86bpm regular

RR18cpm regular

T 36. !

Ht. 170cm" #t. 6.$%g" B&' ((.3 %g/m(

)eneral Sur*e+: c,nsci,us" c,-erent" ambulat,r+" ,riente t, time" pers,n an place ablet,

resp,n appr,priatel+ t, uesti,ns" ell2gr,,me" mes,m,rp-ic b,+

-abitus" spea%s in a n,rmal2pitc-e *,ice" it- g,, t-,ug-t pr,cess an

appr,priate m,, an aect n,t c,m,rtable

Re*ie , S+stems:

o S%in: arm" m,ist" n, lesi,ns" n, acti*e ermat,ses

o H445T:e+ebr,s s+mmetrical" t-in an euall+ istribute" e+elis n,n2

eamat,us"n, matting" n, isc-arge" pin% palpebral c,nuncti*ae" anicteric

sclerae" pupils (23mm euall+ reacti*e t, lig-t" etra,cular muscles ull an eual

o un,sc,p+: 9;re ,range rele" clear isc margin it-


2/10

o !ari,*ascular: nec% *eins n,t istene" ?VP cm at $ egrees angle" car,ti

pulse( amplitue it- rapi upstr,%e an graual ,nstr,%e. @+namic

prec,rium


3/10

alpation

increased

!ascularity and

ecchymosis

No skin

lesions presentexcept for

freckles"

birthmarks or

moles which

may be #at or

ele!ated

Skin is dry

with a

minimum of

perspiration.

$arm and

e%ual

bilaterally.

&ands and

skin slightly

cooler than the

rest of the

body

Skin surfacesnon'tender

exture

Smooth"

e!en and *rm

except where

there is

signi*cant hair

growth

Skin turgor

$hen

released"

should return

to original

contour rapidly

No area of

increased

!ascularity and

ecchymosis

No lesions

$arm and

e%ual

bilaterally


4/10

+dema not

present

Skin sprung

back rapidly

when pinched

No edema

present

Scalp and &air Inspection ,ark black to

pale blonde-

may turn gray

or white- may

be chemically

changed

erminal hair

found in the

eyebrows""

eyelashes" and

scalp" and in

axilla and

pubic areas

after puberty.

No signs of

infestation or

lesions.

Seborrhea

dandru/ may

be present

&air may feel

thin" straight"

coarse" thick

or curly. Shiny

and resilient

&air appears

black with

some white

hair due to

aging.

+!en

distribution of

hair

No

infestation or

lesions

No signi*cant

*ndings


5/10

alpation

&air is thick

and shiny

Nails Inspection

alpation

&a!e a pink'

cast in light'

skinned and

brown in dark'

skinned.

0apillary

re*ll present

(should return

to normal 1'2

sec)

Surface is

smooth" and

slightly

rounded or

#at. 0ur!ed

nails are

normal.

3niform nail

thickness

throughout- no

splintering orbrittle edges.

4ngle

approx. 5678

9irm nail

base

0apillary

re*ll of less

than 1 seconds

Surface

smooth and

slightly

rounded

No splinters

or brittle edges

4ngle

approx. 5678

9irm nail

base

No signi*cant

*ndings

+yes Inspection Symmetrical +yes No signi*cant


6/10

with no

drooping"

infection"

tumors or

other

abnormalities:isual 4cuity

1717

Sclera

$hite in light'

skinned wo

exudates"

lesions or

foreign bodies.In dark'

skinned" may

ha!e brown

patches

upils

e%ually round"

reacti!e to

light and

accommodatio

n- 1'6 mm

No tearing"

swelling or

discharge

symmetrical

Sclera

appears white

upils e%ually

round" reacti!e

to light and

accommodatio

n- approx. ;

mm

No tearing"

swelling or

descharge

*ndings

+ars Inspection


7/10

alpation

position.

roportional.

No redness"

lesions"

swelling"

tenderness

Should not

complain of

pain or

tenderness

position

roportional

No redness"

swelling" or

tenderness

No pain

assessed

Nose Inspection

alpation

Symmetrical"

midline of theface.

$ithout

swelling"

bleeding"

lesions" or

masses.

+ach nostril

patent.

No pain or

discomfort

during

palpation

Symmetrical

and in midline

No swelling"

bleeding"

lesions" or

masses

$ith nasal

#aring.

No pain or

discomfort

noted

No signi*cant

*ndings

his may bedue to

diculty of

breathing and

chest pain.


8/10

in#ammation.

ongue is

midline. ink"

moist" rough

withoutlesions.

Symmetrical-

mo!es freely.

>ums ha!e

pale'red

strippled

surface.

No swelling

or bleeding.

no lesions or

in#ammation

ongue in

midline and

mo!es freely

No swelling

or bleeding

Neck Inspection

alpation

Symmetrical

with head in

central

position. 4ble

to mo!e head

withoutdiscomfort or

noticeable

limits


9/10

alpation

4uscultation

e/ortless

breathing

No

pulsations"

masses"thoracic

tenderness

present.

Normal lung

tissue

produces

resonant

sound"

diaphragm has

dull sounds.

Bronchial"

broncho!esicul

ar or !esicular

breath sounds

rhythmic and

e/ort on

breathing

No masses or

tenderness

cardiomegaly.

4bdomen Inspection

4uscultation

4bdominal

contour #at or

rounded.Symmetrical.

3niform in

color or

pigmentation.

No

abdominal

scars.

No striae

Intermittent

gurgling

sounds

throughout

abdominal

%uadrants.

4bdominal

contour

rounded.

Symmetrical.

3niform in

color.

No scars-

striae

>urgling

No signi*cant

*ndings


10/10

ercussion

alpation

ympany"

predominant

sound heard

No organ

enlargementpalpable" or

any masses"

bulges" or

swelling

sounds in

abdomen

No friction

rubs audible

bruits

Suprapubic

4rea

Inspection

alpation

$ithout

lesions

3rinary

bladder not

palpable and

not tender

$ithout

=esions

3rinary

bladder not

palpable

No signi*cant

*ndings

3pper

+xtremities

Inspection $ithout

lesions" scars

or

in#ammation

$ithout

lesions" scars

or

in#ammation

No signi*cant

*ndings

=ower

+xtremities

Inspection

alpation

$ithout

lesions" scars

No edema

$ithout

lesions" scars

No edema

No signi*cant

*ndings

CONTRAPTURES:

NONE (The patient is f! "is#ha!$e%

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