Integumentary

system
Skin INSPECTION/ Evenly colored skin Inspection -Normal
PALPATION tone, intact skin, Evenly colored
no reddened area, skin tone,
no lesion, intact skin,
no edema, no reddened
warm temperature. area,
Skin pinches easily no lesion,
and immediately no edema,
returns to its warm
original temperature.
position. Skin pinches easily
and immediately -Normal
returns to its
original position.

Head and Face INSPECTION/ Normocephalic and Palpation -Normal

PALPATION symmetrical. Normocephalic,
No lesion visible. no masses or
tenderness notes
upon palpation.
No lesions present.

Scalp and Hair Inspection Hair is black with -Normal

Clean and dry minimal white hair
scalp. Natural hair strands.
color, Smooth and Fewer distribution
firm hair, evenly of hair on the
distributed, no lice, parietal part.
no dandruff. No dandruff
observed.
Nails Inspection -Pink in light -Pinkish in color -Normal
skinned color
- Convex angle of -Normal
nail plate about 160
degrees
- Thick, smooth -Thick, smooth texture, -Normal
texture, high high vascular nail
vascular nail
-      Intact epidermis -Intact epidermis
-     No clubbing of -No clubbing of fingers -Normal
fingers
-Capillary refill -Capillary refill within 2 -Normal
within 2 seconds seconds

Eyes Inspection Placed evenly, Parallel and evenly Pale conjunctiva supports
symmetrical, placed. CVD indication.
non-protruding in Non-protruding
eyes,
pink and clear conjunctiva is pale.
conjunctiva,
white sclera, white sclera
pupils are reactive reactive to light.
to
light.

Ears Inspection Color is the same Color is same in Minimal

with face, face, symmetrical hearing
symmetrically and flexible. problem due
aligned auricle with With minimal to
outer cantus of the hearing problem. manifestation
eye, of old age.
with minimal
hearing problem.

Nose Inspection Symmetrical and Symmetrical, Some

straight. No some uncontrollable
discharges or uncontrollable discharges
flaring. discharges. because of the
feeling of
numbness on the
left side of his
face.

Mouth Inspection Lips are smooth, 24 teeth, Asymmetrical

 moist, pinkish, no l oral mucosa and and
lesion or swelling. lips are pale in uncontrollable
32 teeth and ivory color, moist mouth
color. uncontrollable because of
Gums are pinkish, moist mouth and recent mild
moist, firm there were no oral stroke that
and no masses or ulcers or lesions. causes the
lesion. Midline tongue. numbness
Midline tongue. Present gag reflex. feeling on his
Present of gag Asymmetrical left side face.
reflex. mouth. Pale color supports CVD
indication,

Neck Inspection No palpable masses Uniform in color. -Normal

and no tenderness. No mass.

Lymph nodes Palpation No tenderness, No tenderness, -Normal

no masses, no masses,
no enlargement no enlargement

Posterior Palpation  - Chest wall intact, - Chest wall intact, no -Normal

Thorax and no tenderness, no tenderness, no masses
Anterior Thorax masses -  Fremitus is symmetric
- Fremitus is and easily identified in
symmetric and the lungs.
easily identified in
the lungs. - Resonance tone over
- Resonance tone scapula
Percussion over scapula - Excursion is 3-5cm
- Excursion is 3-5cm bilaterally in women
bilaterally in women and 5-6 cm in merit
and 5-6 cm in merit - Diaphragm is usually
- Diaphragm is higher on the right side.
usually higher on
the right side.   -3 types of normal
 - 3 types of normal breath sounds include
breath sounds bronchial, Broncho-
Auscultation include bronchial, vesicular
Broncho-vesicular - No adventitious
-No adventitious sounds such as crackles
sounds such as and wheezes
crackles and
wheezes.

Heart Auscultation Sound heart beat. Sound heart beat. -Normal

“Lub-dub”. “Lub-dub”.
No murmur. No murmur.

Abdomen Auscultataion/ No discoloration, Non-tender upon -Normal

Palpation lesion, rashes, palpation, flabby,
evenly soft, NABS.
rounded, NABS, no
 masses, swellings,
seldom palpable
spleen.
Upper Equal in length, Equal in length, -Normal
Extremities no lesion, no lesion,
no deformities no deformities on
on extremities extremities and
and with complete with complete
digits. digits.
Uniform body Uniform to body
temperature. temperature.
No edema. No edema.
Skin pinches easily Skin pinches
and immediately easily and
returns to its immediately
original position. returns to its
Normal Capillary original position.
refill Normal Capillary
test. refill test.

Lower Equal in length, Equal in length, -Normal

Extremities no lesion, no lesion,
no deformities on no deformities on
extremities and extremities and with
with complete digits.
complete digits. Uniform to body
Uniform to body temperature.
temperature. No edema.
No edema. Skin pinches
Skin pinches easily easily and
and immediately immediately
returns to its returns to its
original position. original position.
Normal Capillary Normal Capillary
refill refill test.
test.

PHYSICAL ASSESSMENT
Date of Assessment: March 7, 2023
Time of Assessment: 8:00
GENERAL SURVEY:
The patient is conscious, during the interview and physical examination, he had eye to eye
contact and was very cooperative. The patient is coherent and not in distress; his hair colour is
black.