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Area Assessed

This document contains the findings from a physical examination on September 6, 2010 and September 7, 2010. On both dates, the head, hair, scalp, face, eyes, sclera, conjunctiva, nose, mouth, ears, and neck were found to be normal and symmetrical. On the second exam, palpable posterior cervical lymph nodes and decreased red blood cell and platelet counts were noted, indicating the presence of an infection. The thorax, abdomen, and extremities were also examined and found to be normal except for warmth in the extremities due to fever from the infection.

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Astrud Bernadeth Jang
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104 views3 pages

Area Assessed

This document contains the findings from a physical examination on September 6, 2010 and September 7, 2010. On both dates, the head, hair, scalp, face, eyes, sclera, conjunctiva, nose, mouth, ears, and neck were found to be normal and symmetrical. On the second exam, palpable posterior cervical lymph nodes and decreased red blood cell and platelet counts were noted, indicating the presence of an infection. The thorax, abdomen, and extremities were also examined and found to be normal except for warmth in the extremities due to fever from the infection.

Uploaded by

Astrud Bernadeth Jang
Copyright
© Attribution Non-Commercial (BY-NC)
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
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AREA ASSESSED HEAD y y

NORMAL FINDINGS Round and symmetrical. Smooth, without masses or depressions, non tender. Can be black, brown or burgundy (no evidences of Alopecia), no parasites, and the amount is variable Moist, no scars, free from lice and dandruff

ACTUAL FINDINGS September 06, 2010 Round and symmetrical Smooth, without mass and not tender

ACTUAL FINDINGS September 07, 2010 Round and symmetrical Smooth, without mass and not tender

REMARKS NORMAL

HAIR

Black, smooth and no presence of parasites

Black, smooth and no presence of parasites

NORMAL

Moist, no scars, no lice and dandruffs

Moist, no scars, no lice and dandruffs

NORMAL

SCALP

Symmetrical, no edema, no involuntary movements Symmetrical or evenly placed and inline with each other. Non protruding and equal palpebral fissure white, moist and without lesions shiny, smooth, and pink or red, absence of swelling, no lesions and moist

Symmetrical, no edema, no involuntary movements

Symmetrical, no edema, no involuntary movements

NORMAL

FACE

Symmetrical and non protruding

Symmetrical and non protruding

NORMAL

EYES

Symmetrical and non protruding

Symmetrical and non protruding

NORMAL

SCLERA

white, moist and without lesions shiny, not swelling, pale in color

white, moist and without lesions

NORMAL

CONJUNCTIVA

shiny, not swelling, slightly pale in color than before

Decrease RBC count

NOSE

Symmetrically, without swelling, bleeding, lesions,

Symmetrical, no masses, no flaring, bleeding

Symmetrical, no masses, no flaring

Decreased platelet count

or masses. No discharge or flaring and uniform color, MOUTH y pink, soft moist, smooth texture with no evidence of lesions or inflammation. Not crack and symmetrical. Cerumen should be moist and not obscure the lympanic membrane, no foreign bodies, redness, drainage, deformities, nodules or lesions muscles of the neck are symmetrical with the head at a central position pale in color, no lesions or inflammations Slightly pale in color than before, no lesions or inflammations Due to decreased RBC count

EARS

No deformities

No deformities

Normal

NECK

Symmetrical

Symmetrical

Normal

LYMPH NODES

Lymph nodes should not be visible or inflamed and not palpable Quiet, rhythmic respiration. Normal breathing rate
no pain, tenderness, rigidity and muscle guarding Extremities are equal in size No involuntary movements No lesions and edema

(+) palpable posterior cervical lymph nodes

(+) palpable posterior cervical lymph nodes

Presence of infection

THORAX CHEST ANTERIOR

Symmetrical chest expansion, clear breath sounds

Symmetrical chest expansion, clear breath sounds

Normal

ABDOMEN

No pain, no tenderness

No pain, no tenderness

Normal

UPPER AND LOWER EXTREMITIES

y y y

Warm to touch, with IV catheter hooked at right arm.

Warm to touch, with IV catheter hooked at right arm.

With fever due to infection

y y

Temperature is warm and even Can perform ROM

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