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    General Appearance: Ital Sign

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    Liza Estrabo
    The patient is a 47-year-old female in normal general appearance and well-kept. Vital signs were normal except for elevated blood pressure. Physical examination findings were normal for skin, hair, eyes, ears, nose, mouth, neck, chest, abdomen, extremities, and neurological system except for limited range of motion of extremities due to post-operative discomfort from cholecystectomy surgery. The patient was fully conscious and behaving normally during examination.

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    General Appearance: Ital Sign

    Uploaded by

    Liza Estrabo
    113 views4 pages
    The patient is a 47-year-old female in normal general appearance and well-kept. Vital signs were normal except for elevated blood pressure. Physical examination findings were normal for skin, hair, eyes, ears, nose, mouth, neck, chest, abdomen, extremities, and neurological system except for limited range of motion of extremities due to post-operative discomfort from cholecystectomy surgery. The patient was fully conscious and behaving normally during examination.

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    Physical Assessment Final

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    The patient is a 47-year-old female in normal general appearance and well-kept. Vital signs were normal except for elevated blood pressure. Physical examination findings were normal for skin, hair, eyes, ears, nose, mouth, neck, chest, abdomen, extremities, and neurological system except for limited range of motion of extremities due to post-operative discomfort from cholecystectomy surgery. The patient was fully conscious and behaving normally during examination.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    113 views4 pages

    General Appearance: Ital Sign

    Uploaded by

    Liza Estrabo
    The patient is a 47-year-old female in normal general appearance and well-kept. Vital signs were normal except for elevated blood pressure. Physical examination findings were normal for skin, hair, eyes, ears, nose, mouth, neck, chest, abdomen, extremities, and neurological system except for limited range of motion of extremities due to post-operative discomfort from cholecystectomy surgery. The patient was fully conscious and behaving normally during examination.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    General Appearance The patient is 47 y/o, female, with a height of 52 and a weighs 55kgs (121lbs).

    Patients Posture is erect and steady. Nails skin and hair are well maintained and no visible hair loss. The patient is wearing a hospital gown properly tied. She used slippers when walking around the ward. The patient is well kept no signs of body odor. The patient participates willingly on our interview. Patients speech was clear and with coherence. VITAL SIGN Body Temperature Pulse Rate Respiration Blood Pressure Normal Finding 36.5-37.5 60-100bpm 12-20cpm 120/80mmHg Outcome 36 o C 90 bpm 20cpm 140/90 mmHg Analysis normal normal normal Increase Indicates hypertension

    Area Assessed SKIN Color Soles and Palms Moisture Temperature Texture Turgor SKIN APPENDAGES Nails Nail Beds Nail Base

    Technique Inspection Inspection Inspection/Palp ation Palpation Palpation Palpation

    Normal Findings light brown, tanned skin lighter colored palms, soles skin normally dry

    Actual Findings Light brown lighter colored palms, soles skin normally dry

    Evaluation Normal Normal Normal Normal normal Normal

    normally warm Warm smooth and soft Smooth skins snaps back skins snaps back immediately immediately

    Inspection Inspection Inspection

    Capillary Refill

    Inspection/palp ation

    transparent, smooth and convex Pinkish Firm white color of nail bed under pressure should return to pink within 2-3 seconds evenly distributed

    Smooth and convex Pinkish Firm white color of nail bed under pressure return to pink within 2-3 seconds evenly distributed and well kept. Black Moderately

    Normal Normal Normal

    Normal

    Hair Distribution

    Inspection

    Normal

    Color Texture

    Inspection Inspection/palp

    Black Smooth

    normal normal

    ation EYES Eyes Inspection parallel to each other PERRLA -pupils equally round reacted to light accommodation symmetrical in size, extension, hair texture and movement distributed evenly same color as the skin Blinks voluntarily and bilaterally up to 20x/min. do not cover the pupil and the sclera, lids normally close symmetrically transparent with light pink color color is white transparent, shiny black, constrict briskly clearly visible

    rough (wavy hair) Parallel to each other normal

    Visual acuity

    Inspection (penlight)

    PERRLA

    normal

    Eye Brows

    Inspection

    Eyelashes

    Inspection

    symmetrical in size, extension, hair texture and movement Evenly distributed.

    normal

    Normal

    Eyelids

    Inspection

    No discolorations, blink reflex is present and its proportional to the eyes.

    normal

    Conjunctiva Sclera Cornea

    Inspection Inspection Inspection

    Pinkish White coloredTransparent and shiny Colored black and reacts well to the environment. Visible

    normal normal normal

    Pupils

    Inspection

    normal

    Iris EARS Ear canal opening

    Inspection

    normal

    Inspection

    Hearing acuity External part of the Ear

    Inspection

    free of lesions, discharge of inflammation canal walls pink client normally hears words when whispered free of lesions

    free of lesions, discharge of inflammation canal walls pink Client hears words and react normally Free of lesions

    normal

    normal

    Inspection

    normal

    NOSE

    Shape, Size and Skin color

    Inspection

    Naves MOUTH AND PHARNYX Lips Buccal Mucosa

    Inspection

    smooth, symmetric with same color as the face oval, symmetric and without discharge

    Symmetrical to face and is free of lesions. Oval and does not have discharges.

    normal

    normal

    Inspection Inspection

    Gums

    Inspection

    Tongue

    Inspection

    pink, moist symmetric glistening pink soft moist slightly pink color, moist and tightly fit against each tooth moist, slightly rough on dorsal surface medium or dull red

    moist symmetric Soft, moist, pink, and no lesions Pink, wet, no signs of bleeding and intact. Slightly rough, slippery, and is in place without lesions. Yellowish in color, firmly set, no dentures hard palate is dome shaped and soft palate is light pink Neck is symmetrical and has no masses present. neck moves freely without discomfort Skin same color with the rest of the body With dressings on the Right upper quadrant due to surgical incision

    normal normal

    normal

    normal

    Teeth

    Inspection

    firmly set, shiny

    normal.

    Hard and Soft Palate NECK symmetry of neck muscles, alignment of trachea Neck Roll Abdomen

    Inspection

    hard palate -dome shaped soft palate -light pink neck is slightly hyper extended without masses or asymmetry neck moves freely without discomfort

    normal

    Inspection

    normal

    Inspection

    normal

    Inspection

    Skin same color with the rest of the body

    Post-op Cholecystectomy

    EXTREMITIES

    Symmetry Skin Color Hair Distribution Skin Temperature Presence of Lesion ROM NEUROLOGY SYSTEM

    Inspection Inspection Inspection Palpation Inspection Inspection

    symmetrical same with the color of other parts of the body evenly distributed Normally warm no lesions moves freely without discomfort

    symmetrical same with the color of other parts of the body evenly distributed warm No lesions

    Normal Normal Normal normal Due to present condition

    Unable to move freely because of Post op cholecystectomy discomfort

    Level of Consciousness

    Observation

    fully conscious, able to respond to questions, perceptive of events makes eye contact with examiner, hyperactive expresses feelings with response to the situation

    Patient fully conscious, able to respond to questions. makes eye contact with examiner, hyperactive expresses feelings with response to the situation

    Normal

    Behavior and Appearance

    Observation

    Normal

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