Complete Physical Assessment

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| Complete Physical Assessment | Fort Hays State University | NURS603L Health Assessment Across the Lifespan Lab for RNs | Katie Houp | 4/24/2014 |

Complete Physical Assessment of 40 year old male patient seen for assessment purposes. |

Complete Physical Examination
Date: 4/24/2014 Examiner: Katie Houp
Patient: Matt Gender: M Age: 40 Occupation: Medic

General Survey of Patient
Patient is Alert and Orientated to time place and events, appears slightly younger than stated age of 40 years old. Is of African American descent with medium brown pigmentation. Appears well nourished, denies any unplanned weight changes in recent months. Posture and Position: Sitting straight, relaxed with interview process, Obvious Physical deformities: None. Mobility: gait is even, able to ambulate without assistance or use of assistive devices. Full ROM of Joints noted, no involuntary movements noted. Facial expression: Relaxed, pleasant, Mood and affect: laughs with examiner, appropriate for situation. Speech: Clear, even cadence, appropriate word choice, English is noted to be secondary language. Hearing: able to hear whispered words without difficulty. Personal Hygiene: no malodorous smells identified.
Measurement and Vital Signs
Weight: 160 Height: 5’8” Body Mass Index: 24.3
Radial pulse palpated rate and rhythm: strong and regular
Blood pressure: Right arm 118/62
Respirations: observed regular rate and rhythm.
Temperature: not obtained this assessment, Skin noted to be cool to touch
Vision observed without correction
Physical Examination
Head and Face 1. Scalp is intact – no lesions, lumps scaling, parasites or tenderness. Hair is noted to be closely shaved. Cranium is symmetrical in appearance. 2. CN VII, V (Trigeminal, Facial) Intact – Jaw muscles equally strong both sides, able to clench teeth, lift eyebrows, puff…...

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