Introduction:

My client is Chan Wan Yee, a 50-year-old female clerk. Her chief complaint is waist pain. The framework
of the present problem’s history would be OLDCART. The pain started by 2 years, the location is the low
waist back, the pain usually last for few minutes, which is intermittent. The characteristic of the pain is
dull and achy, as she says that it just like the pain are from the bone. There are no associating factors the
pain does not radiate, and it would stop when the action stops, and relieved by resting on bed. The pain
by herniated intervertebral disc could be treated by rest or reducing action. According to the numeric
rating scale (NRS), her pain score is around 8 out of 10. She has the problem of herniated intervertebral
disc. Her family has no hereditary disease. I am going to do a health assessment according to framework
by Bickley & Szilagyi, 2021.

1. Physical Assessment:

1.1 General survey:

She has the problem of obese, with normal appearance and skin. She can have clear communication.
However, she finds her mobility difficult due to the pain. Her conscious level is conscious, with oriented
mental state and calm emotional state.

1.2 Vital Sign:

Her blood pressure is 111/73, with pulse 76 per minute, respiration rate is 15 per minute, weight 67.4
with BMI 23.5, which is normal.
1.3 Physical Assessment:

1.3.1 Skin:

Ms. Chan has a normal yellow tones skin color, with temperature 36.0 ℃ which is in normal range. Her
skin is dry and smooth with normal thickness, and no edema. It is elastic and easy to pinch up skin fold
of forearm and return to normal promptly after release, which shows good mobility and turgor of the
skin. She has a scar on the area of hypogastrium caused by giving birth which is 7cm x1.5 cm.

1.3.2 Hair:

Her hair is black, coarse, smooth, and straight which distributed evenly on scalp. Nil scalp lesion or
dryness was noted.

1.3.3 Nails:

The nail color is pink, the nail plate is slightly curled and its fold look smooth and round, the edge is also
smooth and round with even thickness.

1.3.4 Head and Neck, ENT Eye:

1.3.4.1 Head:

After her hair is parted in several areas, her scalp is inspected. Nil scaliness, lump, nevi or lesion is
noted. Also, through palpation, there are no deformities, depressions, lumps, or tenderness found on
the skull. Then for the face, the skin is in yellow tone, without any pigment, it is smooth, with normal
thickness and have no lesion.

1.3.4.2 Neck:

While inspecting Ms. Chan’s neck, she is sitting still and looking front. Her neck is checked that it is
symmetric and nil masses, scars, enlargement of parotid and submandibular glands, visible lymph nodes
are noted. Also, her neck has full range of motion, and her trachea is in the middle of the neck. No
lymph nodes are palpable. For the anterior superficial and deep cervical chain and supraclavicular
nodes, the nodes are small, mobile, discrete and nontender.

1.3.4.3 Eyes:

In inspections, her eyebrows are evenly distributed, with great fullness and no scaliness. There is no
lesion on her eyelids. And her eyelashes are also evenly distributed and curled upwardly. For the cornea
and lens part, the lens is invisible through pupil under slanting lighting. Then when the light shines from
sideways, there are no shadow on iris. For the pupil size, both eyes are around 2.3 mm in resting state,
and 2 mm in bright light.

1.3.4.4 Ears:

The ears are symmetric, with pointed shape and normal size. Ms. Chan’s skin of ears has no deformities,
lumps, skin lesions, or any tenderness. As to check for the hearing acuity, whisper test is performed. I
stand 2 feet behind her while she is sitting down to prevent being reading lips. Then I gently rub the
tragus of her right ear in circular motion to prevent sound transferring to the right ear. Then I breathe
out fully then I whisper 6 combinations of 3 words and letters randomly. She repeats 5 combinations
correctly, which show that she passes the test and no problem for her hearing acuity.

1.3.4.5 Nose:

Ms. Chan have her nose full patency and can breathe even one side is blocked. Also, her nose has no
discharge. Her nasal mucosa is pink, intact, turbinate is pink, intact, and firm without swelling, bleeding
or crust seen.

1.3.4.6 Oral Cavity

Her lips are symmetric, with pink color and moisten, which have no lumps, ulcers, cracking, and scaling.
She is asked to stick out her tongue for inspection. It is pink and symmetric, with its dorsal surface
roughened by papillae. Then her tip of tongue is grasped and pulled by my gloved hand which holding a
gauze square to check both side and the under surface of the tongue. Nil white or reddened area,
nodules, ulcers, or induration is noted. Her buccal mucosa is pink, moist and no lesion. Her gums are
pink, with nil swelling and ulceration are found in gum margins and interdental papillae. All the molar
and premolar teeth were fallen off. There is no lesion in the whole oral cavity.

1.3.5 Respiratory System: Thorax and Lungs:

1.3.5.1 Posterior:

1. Inspection:

Ms. Chan’s chest is symmetric, and has normal contour and no deformities, and the overlying skin is
intact. The anteroposterior: transverse diameter ratio is 2:1 which is normal. Also, nil use of accessary
muscles (scapulae, scalene and sternocleidomastoid muscles) is noted.

2. Palpation:

Her posterior thorax is palpated, checked that no area with pain, tenderness, lesions, or bruises. Her
chest expansion is checked by putting my thumb close to her spine of the tenth ribs with my fingers
placed on lateral thorax. When she breathes deeply and fully, my divergence of the thumbs is almost 2
cm, and the movement is symmetric. No area of her back thorax has increased, decreased or absent
fremitus while she is saying ‘ninety-nine’.

3. Percussion:

Then her posterior chest is palpated in a systematic manner, from apices to the lung base, moving down
the thorax, moving from side-to-side, which is in a ladder pattern. The percussion sound is resonant for
the percussion tones, but flat for bones and heavy muscles, and dull for organs. To have diaphragmatic
excursion, she is asked to exhale fully and hold her breath. Then find the level of diaphragm by
percussing the intercoastal muscles by the scapular line downward until the tone changes from
resonance to dullness. Then the level is marked and Ms. Chan breaths fully and hold it. Then the new
level of diaphragm is found. The distance of two levels, which mean the diaphragmatic excursion is 4 cm.

4. Auscultation:
1.3.5.2 Anterior:

1. Inspection:

She is asked to lie on bed with face upward. The chest skin is intact, the chest is symmetric with
respiratory movement going upward and outward.

2. Palpation:

The chest has no tenderness, lesions, or abnormalities. Then my thumb is placed along costal margin to
test the thorax expansion, it is symmetric, and the expansion is 4 cm same as posterior thorax. The
fremitus is present except precordium.

3. Percussion:

The anterior and lateral chest is percussed. The precordium presents a sound of dullness, and as the left
midclavicular line is percussed, the resonance of her lung changes to the tympany of the gastric air
bubble.

4. Auscultation:

1.3.6 cardiovascular System:

1.3.6.1 Heart:

1.Inspection:

At the beginning of the examination, Ms. Chan is lying upward on the bed with upper body raised 30
degrees. Nil heaves or lifts is noted on anterior thorax.

2. Palpation:

The apical impulse is located on the fifth intercostal space and left midclavicular line. The rhythm is
regular, with beating rate 76 per minute with a short and gentle tap.

3. Auscultation:

The apical pulse is same as the result of palpation.

1.3.7 Breast:

Ms. Chan is sitting down for the examination. The skin of the breast is in yellow tone, without any
abnormal thickening or prominent pores. The size and shape are roughly symmetric, and without any
massed, dimpling, or flattening. The nipples are having same size and shape, without rashes, ulceration,
or discharge, and they are both pointing outward. Nil axillary nodes are felt during examination.

1.3.8 Abdomen:

1. Inspection:

Ms. Chan is in a supine position. The contour of the abdomen is flat. And it is symmetric. There are no
signs of inflammation or hernias observed on the umbilicus. No peristalsis or aortic pulsations are visible
in the epigastrium. There are an 8cm x 1.5cm scar by giving birth on the hypogastric region. And the skin
is paler than the general skin color.

2. Auscultation:

The bowel sound has a frequency of 20 per minutes.

3. Percussion:

Nil pain noted in the process of quadrant percussion, and dullness is found in the upper right region, and
tympany in the upper left region. I found the liver span is 6cm in midsternal line, and 6cm in
midclavicular line.

4. Palpation:

The liver is not palpable.

1.3.9 Musculoskeletal System:

She has full range of motion (ROM) in body part of cervical spine, elbow, wrist, fingers, ankle, and toes,
while she has limited ROM in body part of shoulder, waist, hip, spine, and knee.

For muscle strength, she has full ROM in both left and right shoulder, biceps, triceps, quadriceps, and
calf.

1.3.10 Neurologic System:

1. Cranial nerve:

For the test for Olfactory nerve, it can function well by identifying the smell. The Optic nerve function
well by reading far object and magazine with glasses with full peripheral visual field. For the
Oculomotor, Trochlear, and Abducens nerves, the test shows that her both eyes move in a smooth and
coordinated motion in all directions, and the pupil size is normal and have suitable reaction to light
reflex. For the Trigeminal nerve, Ms. Chan can move to left and right easily, and she can sense the pain
well. For the Facial nerve, she can have fully facial movement symmetrically. Then for Acoustic nerve,
she passes for the test of whispered voice test. For Glossopharyngeal and Vagus nerves, the uvula and
soft palate rise bilaterally and symmetrically on phonation, and the gag reflex intact. For the Spinal
Accessory nerve, she can against my force on her shoulder while she is shrugging her shoulder and have
enough force to against my hand while she is turning her head against my hand. Then for Hypoglossal
nerve, she has good articulation of words and nil atrophy, fasciculation, asymmetry, or deviation is
noted on her tongue.

2. Motor system:

Her gait is proper. For the Romberg’s test, she is positive, she can stand erect with minimal swaying with
eye close. She can coordinate fast and smoothly proved by Rapid Alternating Movements.

3. Sensory System:

In pain test, she can differentiate the sharp and dull over various body part. In light touch test, she can
correctly identify the light touch. In the position test, she can identify the direction of movement. In
stereognosis, she can identify the shape of an 3D object. In graphesthesia, she can identify the words
written on her hand.

2. Summary

1.Maintaining a safe environment:

She has the risk of fall due to the low waist pain. She can walk with aids like walker. (Berman et al.,
2022)

2. Communicating

She has no problem with communication.

3. Breathing

She has no problem with breathing.

4. Eating and Drinking

She has no problem with intaking food.

5. Eliminating:

She has no problem with elimination.

6. Personal cleansing & dressing:

She has no problem with personal cleansing and dressing.

7. Controlling body temperature:

She has no problem with controlling body temperature.

8.Mobilizing:

She has impaired physical mobility; she is recommended to walk with aids.

9. walking and playing:

She has no problem with walking and playing.

10. Expressing sexuality:

She has no problem with expressing sexuality.

11. Sleeping & rest:

She has no problem with sleeping and rest.

12. Dying:

She has no problem with fear of death.

REFERENCE:
Berman, A., Snyder, S. J., Frandsen, G., Kozier, B., & Erb, G. L. (2022). Kozier & Erb's
fundamentals of nursing: Concepts, process, and Practice. Pearson Education Limited.

Bickley, L. S., & Szilagyi, P. G. (2021). Bates’ guide to physical examination and history taking (13rd ed.).
Lippincott Williams & Wilkins. E-book available:
https://twchk.vitalsource.com/#/books/9781975109943/cfi/6/2!/4/2/2@0:0

Video resource: Bickley, L. S., & Szilagyi, P. G. (2021). Bates’ guide to physical examination and history
taking (13rd ed.). Lippincott Williams & Wilkins.
https://www.twc.edu.hk/en/Administration_Units/lib/e-
resource/electronic_resource/database_subject/page/medical_and_health_science#maincontent