Physical Assessment Case Study

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A.B is a 25 year old female. Today this patient did not seek health care or have any concerns but allowed me to do a complete physical assessment on her for my physical assessment class. This patient states she is in good health at this time. A.B. lives in Avery, Texas with her husband, daughter, and two step daughters. The primary and only language spoken in this household is English. She states she and her family attend church occasionally, when asked how often occasionally is for her she responds “about once a month.” A.B. is currently working at Paris Regional Medical Center as a Nurse Aide on the Oncology floor where she states she “enjoys the interaction with her patients and the teamwork on the floor.” At this time she has some college …show more content…
has no known drug allergies. Her vital signs are as followed 97.3 84 16 124/72 99% on room air. She is awake, alert and oriented to person, place and time. Standing at 5 '7 and weighing 132 pounds she has a tall, thin stature. Skin is tan, warm and dry. No bumps or bruises are noted to any of the skin. A tattoo is noted to her right shoulder of a crown. The second tattoo noted is on her right forearm of a heart locket, the third is on her left side of two pistols that cross. The last tattoo seen is on her right foot of a butterfly which is faded. The patient states this was her first tattoo that she received when she was sixteen. While assessing the scalp there are no bumps, bruises or lesions seen, the hair is brown, free of dandruff, long, thick and evenly distributed. Ears are symmetrical and free of ear wax bilaterally. Both tympanic membranes are pearly gray with no redness or drainage noted. No complaints of ringing in the ears or previous ear infections. Hearing is tested in both ears per the whisper test which is equal bilaterally. Eyebrows evenly distributed. No tenderness or swelling noted in sinus ' and has no history of sinus infections. Eyes are symmetrical, brown in color, positive perrla assessed, pupil size of 3mm in both eyes. Patient states she has never had any problems with her eyesight. Conjunctiva pink and sclera white with no redness or drainage from eyes. No deviated septum to nasal passage. Oral mucosa free of lesions while mucus membranes pink, moist and intact. Multiple dental caries present to teeth. Patient states she “frequently has toothaches but has a dentist appointment next week to get her teeth fixed. No enlarged lymph nodes or JVD assessed to neck. Patient has no difficulty breathing or shortness of breath and states she has no history of respiratory issues. Lung sounds are clear and loud to auscultation on inspiratory and expiratory times fives lobes. Breasts are even with no complaints of tenderness. Auscultated apical

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