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Physical Assessment For Case Pre With Ros

The document summarizes the results of a physical examination of a patient's skin, nails, head, face, hair, eyes, ears, nose, mouth, throat, neck, chest and cardiovascular system. The exam found the patient's skin, nails, head, face, hair, eyes, ears, nose, mouth, throat, neck and chest to be normal, symmetrical and without lesions, tenderness or abnormalities. The patient's heart and lung sounds were also normal without abnormal sounds detected.

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Joule Peirre
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200 views4 pages

Physical Assessment For Case Pre With Ros

The document summarizes the results of a physical examination of a patient's skin, nails, head, face, hair, eyes, ears, nose, mouth, throat, neck, chest and cardiovascular system. The exam found the patient's skin, nails, head, face, hair, eyes, ears, nose, mouth, throat, neck and chest to be normal, symmetrical and without lesions, tenderness or abnormalities. The patient's heart and lung sounds were also normal without abnormal sounds detected.

Uploaded by

Joule Peirre
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

PARTS ASSESSMENT REVIEW OF SYSTEMS

SKIN INSPECTION
 Warm to touch
 No lesions nor rashes seen
 Has fair-light and brown
skin
 No presence of any foul
odor
PALPATION
 Skin turgor is firm
NAILS INSPECTION
 Clean and cut nails noted
 No presence of clubbing
PALPATION
 Capillary nail refill is less than
2 seconds
HEAD INSPECTION
 Head is symmetrical
 Has the same color with the
skin
 No lesions seen
 No headache upon assessment
PALPATION
 No tenderness
FACE INSPECTION
 Round in shape
 Symmetrical
 Same color as the skin
 No presence of nodules,
lesions
 No involuntary muscle
movements
 Eyebrows are evenly
distributed
 Eyelashes appeared to be
equally distributed and slightly
curled outward

PALPATION
 Absence of edema

HAIR INSPECTION
 No signs of infection and
infestation
 Black, coarse, thick and ruffled
long hair
 Hair is evenly distributed
EYES INSPECTION
 Both eyes can see clearly
without using eyeglasses
 Pupils are equal, round,
reactive, to light and
accommodation
 Sclera appeared white
 Conjunctiva appeared
transparent with few
capillaries evident
 Pupils of the eyes are black in
color
 No yellowish discoloration
 Cornea is clear
 Iris appears flat

EARS INSPECTION
 Has the same color with skin
 Earlobes are bean-shaped,
parallel, and symmetrical
 Auricles are symmetrical and
aligned to the outer canthus of
the eye
 Ear canal has normally some
cerumen
 Both ears are able to hear
clearly
 No discharges seen
PALPATION
 Pinna recoils when folded
 Auricles are firm and no
tenderness

NOSE INSPECTION
 Symmetric, straight and
 Nasal septum is in the middle
and not perforated
 Same color with the skin
 Symmetric and no nasal flares
 No frequent colds
 No inflammation
 Both nares are patent
 No allergies
PALPATION
 No tenderness and lesions
noted
 No bone and cartilage noted
MOUTH AND THROAT INSPECTION  Yellowish teeth due to
 Chapped lips poor oral hygiene
 Symmetric
 No bleeding on the gums
 No dentures
 Yellowish teeth
 Absence of toothache and
dysphagia
 No swelling of the gums
 The tongue is centrally
positioned, pinkish in color
and presence of thin whitish
coating
 Tongue is able to move freely
 The uvula is positioned in the
midline of the soft palate
NECK INSPECTION
 Same color as the skin
 Neck muscles are equal in size
 Pt showed coordinated,
smooth head movement with
no discomfort
 No lesions seen
 Thyroid gland is not visible
 No jugular vein distension
PALPATION
 Lymph nodes are not palpable
 Trachea is placed in the
midline of the neck
CHEST INSPECTION
 Same color as the skin
 Has symmetric expansion
 Breast has darken areola
 Breast has milk and engorged
 No visible deformities such as
scoliosis
PALPATION
 Chest wall is intact without
tenderness and masses
 No retractions or dimpling
 Apical pulse is palpable
PERCUSSION
 Resonance heart sound heard
over a normal air filled lung
AUSCULTATION
 No abnormal heart sound
heard such as rhonchi,
murmuring, wheezing

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