Running Header: PHYSICAL ASSESSMENT Physical Assessment

Physical Assessment
Connie Wilson
NURS 3293
Columbus State University
Current Health Status
I performed my physical assessment on a 75 year old female who is retired and lives with her
spouse. The assessment took place in her home for the purpose of assisting me with this
assignment and has no physical complaints at this time. She is currently monitored for the
following conditions: Hypertension, Hypothyroidism, Renal Insufficiency, Osteoarthritis,
glucose intolerance, anxiety and Polycythemia. She has had several recent incidents of falling
and “passing out”, the cause remains unidentified.
Past Medical History
When asking the patient about past health issues I get some conflicting information. She denies
having chicken pox, but has had shingles in 1981, and reports having mumps at the age of 24.
Her surgical history includes a Thyroidectomy in 1962, Hysterectomy in 1977, ORIF right ankle
in 1998, Fusion of right ankle in 2001, Cholecystectomy in 2007, right total hip replacement in
2011, and left total hip replacement in 2012. She had a DVT in 2010 and also had a stent placed
in her left shoulder on 2013 for another blood clot. She is a gravida 3 and para 3, her first child
was born at the age of 19.
The patient recently had her flu vaccination within the past week but refuses the pneumonia
vaccine. She has not had the shingles vaccine and is current on her tetanus. She routinely sees
her dentist for preventative and correctional care; mammograms are done yearly, and she has not
seen a gynecologist is several years. She utilizes a chiropractor for complaints of occasional back
discomfort. She reports exercise is nonexistent due to leg weakness and instability. There have
not been in dietary changes nor any weight loss or gain. No known drug or food allergies.
Family History
Mother – Cervical and Colon cancer, Myocardial Infarction (MI), Transient Ischemic Attack
(TIA), Hypertension (HTN), dementia, and Diabetes Mellitus (DM), died at age of 85 due to
Father - MI, died at age of 43.
Brother - Coronary Artery Disease (CAD), DM, MI, smoker, died at age of 65 due to CAD.
Sister – Congestive Heart Failure (CHF), DM, Lung cancer, renal failure, alcohol abuse, smoker,
died at age 65 due to multiple issues listed.
Brother – CAD, MI, DM, smoker, died at age 58 due to CAD and DM.
Patient denies use of recreational drugs, does not smoke, and has an alcoholic beverage one to
two times yearly. Hobbies include reading to relax, baking, and enjoys attending the local Baptist
Losartan 50mg BID for HTN
Premarin 0.9mg 6 tabs weekly for hormone replacement therapy
PreCrea (dose unknown) 2 tabs daily for impaired glucose tolerance
Calcitrol 0.25mcg, 3 tabs daily, calcium replacement due to hysterectomy
Hydroxyurea 500mg, 1 cap daily for Polycythemia
Warfarin 2.5mg daily, for history of blood clots
Levothyroxine .088mg daily for hypothyroidism
Citalopram 20mg daily for anxiety
Bystolic 5mg daily for HTN
Losartan 50mg BID, for HTN
Lorazepam 0.5mg prn for SBP > 160
Hydroxyzine 25mg prn for itching
Nitrostat 0.4mg prn chest pain
Glucosamine/Chondroitin 1500mg daily, supplement for joint mobility, OTC
Dermex-P 1 tablet daily, supplement for skin, OTC
Mini-Mental Examination
The Mini –Mental Status Examination was performed, the patient scored 30, with the maximum
score available being 30. The breakdown of the scoring is as follows:
Orientation to Time- scored 4 out of 5
Orientation to Place-scored 5 out of 5
Immediate Recall- scored 3 out of 3
Attention-Part A- scored 2 out of 5
Part B-scored 5 out of 5
Delayed Verbal Recall- Part A-scored 2 out of 3
Naming-scored 2 out of 2
Repetition-scored 1 out of 1
3-Stage Command-scored 3out of 3
Reading, Writing, and Copying-scored 3out of 3
24 Hour Food Diary
Food Item
Calorie Count
1 cup
whole milk
1 cup
peanut butter/jelly
whole milk
1 cup
whole milk
1 cup
energy bar
Dietary Education
I attempted to discuss adding vegetables in her meals to encourage a balanced diet; she was very
resistant to the conversation. I did note a cake (half eaten) in the kitchen and encouraged her to
drink more water. She does not cook dinner as frequently as she once did. She is capable of
cooking with no barriers other than a lack of desire to do so. As a last attempt, I suggested
adding BOOST or Ensure to get the vitamins and minerals she is most likely missing. The
response was about the same.
Physical Assessment
After cleaning my hands I began the physical assessment by letting her know if she felt
uncomfortable at any time to let me know and we would stop the process or change what we
were doing. I asked her to have a seat, then assessed for orientation, along with verbal and motor
response. The Glasgow Coma Scale score was 15, resulting in a normal score. Vital signs at the
time of the exam were: B/P 172/82, HR 80, R18 and regular, T 98.5 orally.
I began by an overall observation of her appearance; her skin is even in color and clean with no
signs of cyanosis or jaundice. One small ecchymotic area noted on left forearm, asked patient
about this and she responded this was a result of her taking Coumadin. Scars were noted on
bridge of nose, neck, and right ankle. Patient reports scar on the nose resulted from a recent fall,
she had a thyroidectomy in the past, and the scar on the ankle was from a fusion surgery. She
also reports she has scars on each hip due to hip replacement surgery. Her skin is thinning,
tenting noted bilaterally on hands, small superficial veins noted around ankles and legs were
clean shaven, therefore I was unable to assess for hair distribution on legs. Hair on forearms was
absent and eyebrows were thin, with outer third of brow absent. Patient denies any skin
complaints other than dryness which she treats successfully with over the counter (OTC)
products. No rashes or lesions were found, she sees a dermatologist routinely for skin cancer
screenings. She does have a history of sunbathing and sunburn. Temperature equal bilaterally
when hands and feet were assessed. Feet noted to be slightly cooler to touch.
The patient was wearing artificial nails and toenails were painted, she is clean and wellmanicured. Fingertips were of normal shape and capillary refill was less than 3 seconds on
fingers and toes which is considered “brisk” in description. No indications of cyanosis or
clubbing noted.
Patient’s hair is thinning and she routinely colors. No skin abnormalities noted on the scalp, she
denies itching, dryness, eczema, or any other scalp conditions. Palpation of scalp reveals normal
shape and symmetry, no abnormalities were felt. Patient denies any pain or tenderness upon
Ears are equal in size and shape bilaterally; they are clean and free of drainage or redness. She
denies any pain or tenderness. She does have hearing loss bilaterally and wears hearing aids. She
was not wearing them during the assessment and failed the whisper test.
Face is symmetrical, no drooping of eyes, smile is equal. I performed the cotton ball test to
assess the trigeminal nerve, also called cranial nerve 5, which she passed. No deficits were noted.
I palpated her sinuses, patient denied pain or tenderness.
Eyes, Nose, and Throat
We began her eye exam with the Snellen eye test, she stood 20 feet away from the chart and read
the smallest line possible with each eye and she had a result of 20/40 bilaterally while wearing
her glasses. We then did the near vision test, she struggled with the exam and her results were
16/160 in the right eye and16/80 in the left eye while wearing her glasses. She did not seem
surprised by the results and reports she has had trouble seeing recently. She has an existing
appointment scheduled for the near future with her eye doctor. Her pupils were checked with a
pen light, they were equal and reactive to light with good accommodation. The six cardinal fields
of gaze were checked and no nystagmus was seen. Confrontation was assessed and no deficits
were noted. The vision tests checked cranial nerves 2, 3, 4, and 6, which are the optic,
oculomotor, trochlear, and abducens. Observation of the sclera is white, no halos noted around
the iris, mucus membranes are pink and moist, eyes are of normal shape with no drainage, and
eyelashes are present. She wears glasses and sees her eye doctor regularly.
The nose was checked for patency bilaterally, each side was clear and free of drainage. A smell
test was performed to check the olfactory nerve, cranial nerve 1.Hand sanitizer was used to
perform the test and no deficits were found. The bridge of the nose was slightly swollen and a
scar was found, she reported this was a result of the fall she had recently. The bridge of the nose
was fractured, therefore palpation was not performed.
Observation of throat began with mucous membranes moist and pink in appearance. There were
no lesions or abnormalities seen, asked the patient to say “ahhh”, the uvula remained midline.
The hard and soft palates appear normal. She was able to swallow water without difficulty.
This was an assessment of cranial nerves 9 and 10, glossopharyngeal and vagus nerves. She
denies having any problems or complaints with her throat or swallowing and denies hoarseness.
She is able to move tongue side to side and up and down, with and without resistance, this
assesses cranial nerve 12 which is the hypoglossal nerve.
Patient has had a thyroidectomy in the past, therefore palpated only to assess swallowing. No
abnormalities were noted. She is able to turn head side to side, with and without resistance, also
at this point, let it be noted that there were no pulsations to be seen to indicate higher vascular
pressures. When asked, the patient performed a shoulder shrug with and without resistance, this
assessed cranial nerve 11 which is the accessory nerve. She denies having any neck discomfort
other than the occasional “stiff neck” after sleeping on it wrong. At this point I palpated the
lymph nodes. I began with the retro-pharyngeal, then to pre and post auricular, occipital, moved
down the cervical chain feeling for deep and superficial nodes and ended at the supraclavicular
site. No lymphadenopathy was noted. Patient denied any tenderness at any of these locations.
Breast Exam
Breast exam was performed, palpation around breast revealed no abnormalities. Self-breast exam
teaching was provided; patient was able to demonstrate how to perform and states she checks
almost every week. As stated previously, mammograms are performed routinely.
I began assessing her cardiovascular system by checking pulses. Brachial pulses were difficult to
palpate, therefore I rated them at 1+ bilaterally, radial pulses bilaterally were 2+, popliteal were
2+ bilaterally, and dorsalis pedis were 2+ bilaterally. I also checked the temporal and carotids
bilaterally and all were 2+. At the temporal and carotid locations I listened for bruits with the bell
of my stethoscope and none were heard. I found no edema around the eyes or extremities. Patient
does report that ankles swell occasionally if she stands for too long, elevating the legs corrects
the problem. She denies any extremity pain.
Auscultation of the heart was performed as follows with the diaphragm of the stethoscope:
Right sternal border (RSB) and 2nd intercostal space (ICS), the aortic valve is assessed and S2
should be louder than S1. Normal sounds were heard.
LSB and 2nd ICS, the pulmonic valve is assessed and S2 should be louder than S1. Normal
sounds were heard.
LSB and 3rd ICS, the ERB’s point is assessed and S2 and S1 should be equal. Normal sounds
were heard.
LSB and 4th ICS, the tricuspid valve is assessed and S1 should be louder than S2. Normal sounds
were heard.
LSB and 5th ICS, the mitral valve is assessed and S1 should be louder than S2. Normal sounds
were heard.
No extra sounds such as clicks, extra beats, or murmurs were heard. Recent echo revealed
normal findings per patient. I asked the patient to hold her breath at each location while I listened
for bruits. None were heard. Patient denies having shortness of breath at either rest or on
exertion. She is able to walk a flight of stairs without difficulty. She had an episode of chest pain
last year which resulted in an infection being the cause. The hospital gave her a prn order for
Nitrostat that she does not use.
Observation of patient’s chest reveals normal shape; respirations are even, regular, and
unlabored. I auscultated lung sounds with the diaphragm of the stethoscope anteriorly, laterally,
and posteriorly at all three levels. All lung sounds were clear, no wheezing, crackles, or rales
heard. Patient denies complaints of recent illness, shortness of breath, or discomfort. I palpated
for tactile fremitus while the patient counted to 100 and had a positive result posteriorly between
the scapulae. I placed hands posteriorly, near bottom of ribs and asked patient to breathe in and
out. Rise and fall is equal bilaterally. Patient has no current respiratory issues that she sees a
physician for.
Initial observation noted that patient’s finger joints were swollen and deformed. Patient reports
she has osteoarthritis and scoliosis. I asked patient to stand and bend over if possible, spine is
curved, and one hip is noted to be higher than the other. Kyphosis is also noted. She has a history
of a fractured ankle where arthritis became aggressive and the ankle had to be fused.
Osteoarthritis is also responsible for bilateral hip replacements. TMJ joint was palpated and no
abnormalities were found. Patient will take occasional Tylenol for pain relief. I assessed patient
for strength, while grips were weak, they were equal bilaterally. Patient’s gait is slow and
cautious, educated her on picking up her feet to prevent catching toe of shoes to prevent falls.
We also talked about safety, removing throw rugs and keeping floor free of clutter. Patient was
receptive to this advice.
Neurological Assessment
Most of the neurological assessment was performed during other sections of the physical exam;
cranial nerve (CN) 1 was the olfactory nerve and was assessed performing the smell test. We
assessed vision and cranial nerves 2, 3, 4, 6 which are the optic, oculomotor, trochlear, and
abducens. CN 5, trigeminal nerve, was assessed with the cotton ball test. CN 9 and 10,
glossopharyngeal and vagus nerves were assessed when the throat was examined and the
swallow test was performed. CN 11 is the accessory nerve and was assessed while checking the
shoulder shrug, and CN 12 is the hypoglossal nerve and was assessed when patient was asked to
perform tongue movements.
A sharp/dull test was performed on her extremities and no deficits were found. She was able to
identify an object in her hand while eyes were closed, I also traced a number in her palms while
eyes were closed and she was able to identify the number correctly. These assessments are
checking for cortical diseases. Reflexes were assessed; I checked biceps, triceps, and patella
reflex points bilaterally with a reflex hammer, I received negative results on all except the right
patella which was graded at a 2+.
I asked patient to perform a rapid hand movement, she is able to follow directions and perform
correctly, although speed was a little slow. Finger to nose was performed without deficits. She
was unable to perform the heel to toe walk due to balance issues.
I asked patient to lie down on sofa to assess abdomen. I listen for bowel sounds in all four
quadrants with the diaphragm of the stethoscope, all were active. I also listened for bruits while
patient was in this position. I assessed the renal, iliac and aortic arteries with the bell of the
stethoscope. No bruits were heard. I then palpated the abdomen in all quadrants; patient denies
any pain or tenderness. Femoral arteries were assessed, each side was strong and given a 2+.
While patient was in this position, I assessed the strength in the lower extremities by having her
push with her feet against my hands and then pull against my hands. She was equal bilaterally.
Overall, the patient is compliant with medical treatments and follows up with appointments for
preventative and follow up care. She is resistant to dietary recommendations and has a habit of
trying expensive supplements to self-treat her medical problems; an example of this is the
PreCrea that is sold off of Amazon. She refuses to have a conversation about this area. The
arthritis has limited her movements, making exercise difficult. Falling is her biggest risk at the
moment due to taking Coumadin. I would recommend an appointment with a dietician to assist
in improving her diet.