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    Case Analysis (Physical Assessment)

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    angelsyke
    This document provides a head-to-toe assessment of body parts and their normal and actual findings. It notes that the patient has dry, dark skin and an enlarged abdomen. The interpretation is that the patient likely has myomas or fibroids, which are non-cancerous tumors that originate in the smooth muscle of the uterus and can cause abdominal enlargement.

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    Attribution Non-Commercial (BY-NC)
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    Case Analysis (Physical Assessment)

    Uploaded by

    angelsyke
    919 views4 pages
    This document provides a head-to-toe assessment of body parts and their normal and actual findings. It notes that the patient has dry, dark skin and an enlarged abdomen. The interpretation is that the patient likely has myomas or fibroids, which are non-cancerous tumors that originate in the smooth muscle of the uterus and can cause abdominal enlargement.

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    CASE ANALYSIS (PHYSICAL ASSESSMENT)

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    This document provides a head-to-toe assessment of body parts and their normal and actual findings. It notes that the patient has dry, dark skin and an enlarged abdomen. The interpretation is that the patient likely has myomas or fibroids, which are non-cancerous tumors that originate in the smooth muscle of the uterus and can cause abdominal enlargement.

    Copyright:

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

    Case Analysis (Physical Assessment)

    Uploaded by

    angelsyke
    This document provides a head-to-toe assessment of body parts and their normal and actual findings. It notes that the patient has dry, dark skin and an enlarged abdomen. The interpretation is that the patient likely has myomas or fibroids, which are non-cancerous tumors that originate in the smooth muscle of the uterus and can cause abdominal enlargement.

    Copyright:

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

    BODY PARTS NORMAL ACTUAL INTERPRETATION

    FINDINGS FINDINGS / ANALYSIS with


    REFERENCE
    SKIN Skin is unblemished, no Dry skin, dark in color
    scars, color is uniform, scaly.
    hair evenly distributed,
    good skin turgor.
    SKULL Proportional to the size Proportional to the size
    of the body, with of the body, with
    prominences in the prominences in the
    frontal area anteriorly frontal area anteriorly
    and the occipital area and the occipital area
    posteriorly, semetrical posteriorly, semetrical
    in all planes, gently in all planes, gently
    curve. curve.
    SCALP White, clean free from
    masses, lamps scars nits
    dandruff, and lesions,
    no areas of tenderness.
    HAIR Black evenly distributed
    and covers the whole
    scalp, thick shiny free
    from split ends, the
    texture is fine.
    FACE Oblong , or oval, or
    square, or heart shape,
    symmetrical, facial
    expression that is
    dependent on the
    mood, or true feelings,
    smooth and free from
    wrinkles, no involuntary
    muscles movement.
    EYES Parallel and evenly
    placed, symmetrical,
    non protruding, with
    ‘scant amount of
    secretions, both eyes
    are black and clear.
    EYEBROWS Black, symmetrical,
    thick, can raise lower
    eyebrows symmetrically
    and without difficulty,
    evenly distributed and
    parallel with each
    other.
    EYE LASHES Black evenly distributed
    and turned outward
    EYE LIDS Upper lids cover small
    portion of the iris and
    the cornea and the
    sclera when the eyes
    are closed the lids meet
    completely.
    Symmetrical, color is
    the same as the
    surrounding skin, no
    palpable mass.
    LIDS MARGIN Clear, without scaling or
    secretions, lacrimal duct
    openings or evident at
    the nasal ends of the
    upper and lower lids.
    SCLERA White and clear
    IRIS Proportional to the size
    of the eye, round
    black/brown, and
    symmetrical.
    PUPILS From pin point to
    almost the size of the
    iris , round symmetrical,
    constrict with
    increasing light and
    accommodation
    EARS Parallel symmetrical
    proportional to the size
    of the head, been
    shaped, helix is in the
    line with the outer
    canthus of the eye, skin
    is the same color as the
    surrounding area, clean.
    Firm cartilage.
    NOSE Midline symmetrical,
    and patent.
    LIPS Pinkish, symmetrical lip
    margin well defined,
    smooth and moist.
    GUMS Pinkish, smooth, moist,
    no swelling, no
    retraction, no
    discharge.
    TEETH 32 permanent teeth,
    well aligned, free from
    caries or filling, no
    halitosis.
    TOUNGE Large, medium, red or
    pink, slightly rough on
    top, smooth, along the
    lateral margins, moist,
    shiny, and freely
    movable.
    NECK Proportional to the size
    of the body and head,
    symmetrical, straight,
    no palpable lumps,
    masses, or areas of
    tenderness.
    ABDOMEN Skin is unblemished, Enlarge abdomen Myoma/Faroids
    no scars, color is originate in smooth
    uniform, symmetrical muscle cells of the
    movements caused by uterus. Tumors form
    respiration, aortic in the uterine cavity,
    pulsation at on the outer surface of
    ephigastric area the uterus or in the
    visible in thin persons, wall of the uterus
    umbilicus is flat or itself. They can also
    concave, positioned grow on stalks and
    midway between the protrude into the
    xyphoid process and cervical canal that
    the symphasis pubis, cause an enlargement
    color is the same as of the ebdomen.
    the surroundings skin.
    ARMS Skin colors varies
    (pinkish,tan,dark
    brown)symmetrical,
    fine hair evenly
    distributed,
    presence/absence
    Of visible veins
    Palpation: warm , dry
    and elastic, no areas of
    tenderness, muscle
    appears equal with
    good muscle tone.
    LEGS

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