Physical Assessment Essay

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Objective Data/Physical Assessment of Patient B.P. Vital Signs: Pulse 68 beats per minute, 2+, regular, steady; Respirations 14 beats per minute, relaxed, even, and unlabored; B/P 118/78 mmHg, left arm, sitting; Temperature is 98.9 F°. Measurements: Ht: 6 '1" Wt. 165 lbs. BMI 21.8. General Survey: B.P. 21 y.o. Well nourished Caucasian male that is awake, alert, and orientated times 3. He appears to be stated age and gender. Body build and facial features are symmetrical on both sides with an alert expression and is responsive. Posture is erect, gait is normal and smooth, with slight discomfort with sitting position. Full ROM. Dressed appropriately for the occasion and for the weather. Clean and well groomed. Skin, Hair, and Nails: No nasal …show more content…

Patency is intact, able to sniff through both nostrils. Color of nose is pink, septum is midline, no swelling, exudate, bleeding, ulcers, or polyps noted. Cranial Nerve I: Olfactory intact. Frontal and maxillary sinuses are nontender and no fluid present. No odors present. Lips are pink, moist, smooth, no lesions, ulcers or abrasions noted. Buccal mucosa pink, moist, with no exudates, lesions or abrasions noted. Stensen ducts and Wharton ducts present with no swelling or tenderness. 28 pearly white symmetrical teeth with no broken or missing teeth. Gums are pink with no swelling or tenderness. Ventral surface of tongue is pink, moist. Frenulum is midline Tongue is able to push against force in both ways. Able to say “light, tight, dynamite.” Gag reflex intact. Soft palate is smooth and pink and is able to rise when saying “Ahh”. Able to swallow. Cranial Nerve IX, X, and XII: Glossopharyngeal, Vagus, and Hypoglossal intact. Throat is pink, moist, no lesions present. Uvula is midline with no swelling or redness noted. Tonsils are pink, symmetrical, and visible (slightly) …show more content…

20/20 with no corrections, O.D. 20/20 with no corrections. Peripheral vision is intact. Corneal light reflex is symmetric bilaterally. Extraocular movements are smooth and symmetric, with no nystagmus noted. Eyelids are symmetrical bilaterally with no drooping present. No redness, discharge, or crusting noted on lid margins bilaterally. Bulbar conjunctivas in left and right eye are pink, moist, and smooth; sclera is white. No swelling, tenderness, or redness over lacrimal gland bilaterally. Puncta is visible, without swelling or redness bilaterally. No drainage present. Cornea is transparent, smooth, and moist with no opacities bilaterally. Irises are round, flat, and evenly colored. Pupils are round, reactive to light and accommodation, 4 mm is the size bilaterally. Pupils can converge evenly. Red reflex is present bilaterally. Optic discs are creamy white in color, margins are present and retinal vessels are red in color bilaterally. Retinal background free of lesions and orange-red in color bilaterally. Unable to find macula upon

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