The patient is a 24 -year-old Mexican female. She is Catholic and is currently a Bachelor’s student at West Coast University, Ca. There is no history of surgeries. She has a family history of diabetes from her mother’s side and hypertension from her father’s side. She mentioned that she is not diabetic but her mother is. She recalled her last physical examination was during her junior year in high school but it was not a full physical assessment. It was a requirement to attend her physical education class and in order to play sports. She mentioned that it wasn’t a full head-to-toe but just vitals, history of asthma and eye exams. Her last menstrual period was October 2, 2015. Patient came into the clinic to have a full Physical Assessment,
…show more content…
Client’s posture and gait are normal, smooth, and balanced. The client was alert and oriented to person, time, place, and event. Light flaking was observed due to sunburn and facial skin showed presence of acne on left lower jaw and chin. Ears and nose are normal as well with presence of flaking on both ears due to sunburn. Face was symmetrical. Pupils were equal, round, reactive to light, and accommodating. The “h” method was performed to test for the six cardinal fields of gaze and client responded normally. The client’s internal and external eye showed no abnormalities. The conjunctiva was clear and pink of the underlying tissue. Red reflex and peripheral vision were assessed and normal. Nose showed no signs of inflammation or redness and it was clear of lesions or drainage. Nasal Patency was normal with no obstructions bilaterally. Client’s sinuses were inspected and palpated and showed no signs of discomfort or inflammation. Mouth was pink and moist with no pain or abnormalities. Client’s teeth were straight and clean and wisdom teeth are still present. Gums were pink and moist with no pain. Mucous membranes were pink, moist, and smooth with no lesions. Salivary glands had no pain, tenderness, swelling or redness. Tongue is pink, moist with no lumps or masses present. Assessment of the neck and lymph nodes showed no swelling of the thyroid glands and the lymph nodes. Client also stated no pain in these areas. The ears were symmetrical and did not have any lesions, tenderness, drainage or pain upon inspection and palpation. Romberg test was performed and client displayed normal equilibrium (D’ Amico & Barbarito, p.327,
Client’s posture and gait are normal, smooth, and balanced. The client was alert and oriented to person, time, place, and event. Light flaking was observed due to sunburn and facial skin showed presence of acne on left lower jaw and chin. Ears and nose are normal as well with presence of flaking on both ears due to sunburn. Face was symmetrical. Pupils were equal, round, reactive to light, and accommodating. The “h” method was performed to test for the six cardinal fields of gaze and client responded normally. The client’s internal and external eye showed no abnormalities. The conjunctiva was clear and pink of the underlying tissue. Red reflex and peripheral vision were assessed and normal. Nose showed no signs of inflammation or redness and it was clear of lesions or drainage. Nasal Patency was normal with no obstructions bilaterally. Client’s sinuses were inspected and palpated and showed no signs of discomfort or inflammation. Mouth was pink and moist with no pain or abnormalities. Client’s teeth were straight and clean and wisdom teeth are still present. Gums were pink and moist with no pain. Mucous membranes were pink, moist, and smooth with no lesions. Salivary glands had no pain, tenderness, swelling or redness. Tongue is pink, moist with no lumps or masses present. Assessment of the neck and lymph nodes showed no swelling of the thyroid glands and the lymph nodes. Client also stated no pain in these areas. The ears were symmetrical and did not have any lesions, tenderness, drainage or pain upon inspection and palpation. Romberg test was performed and client displayed normal equilibrium (D’ Amico & Barbarito, p.327,