Physical Assessment A. General Appearance The client has small frame body built with stumbling gait.

Dressed appropriately with no body or breath odors. The clinical measurements include the height which is 156 cm, weight of 50 kgs. Vital signs includes temperature of 37 degrees Celsius, blood pressure of 120/80 mmHg, respiratory rate of 19 cpm and pulse rate of 69 bpm. B. Mental Status The client is lethargic. Oriented to time, place and person. C. Skin He has normal racial tome which is brown in color. The temperature is warm. Moisture is dry while texture is rough. Hair is evenly distributed. D. Nails The nail plate shape is convex, with smooth nail condition and pale nail bed color. Capillary refills within 3 seconds. E. Head and Face Skull is proportionate with the body size. Scalp is white with no tenderness and lesions. Hair is evenly distributed and the hair is brittle. Facial features and facial movements are both symmetrical. F. Eyes Eye condition is straight normal. Eyebrows, eyelids and lashes are thin and evenly distributed. Has frequent blinking reflex. Eyeballs are symmetrical. The bulbar and palpebral conjunctiva are pink. The pupils 2-3 mm equally briskly reactive to light. Lacrimal apparatus are moist, double vision of the eyes. G. Ears Auricles have a normal racial tone which is brown in color. It is symmetrical and elastic. Pinna recoils when folded. H. Nose External nose has a normal racial tone which is brown. Septum is on midline. Mucosa is reddish. Nasal cavity is both patent. Sinuses are non-tender, no nasal congestion. I. Mouth Lips are pale and symmetrical. Mucosa is pale. Tongue is on midline and can swallow. It is rough, red in color and movable.

J. Pharynx Uvula is on midline. Mucosa is pale. Tonsils are not inflamed. Lymph nodes are not palpable. Gag reflex is present. K. Neck Neck muscles are equal in size. Muscle strength is with resistance with a grade of 3/5. Lymph nodes are not palpable. Trachea is on midline and thyroid gland is not palpable. L. Breast and Axilla Breasts are symmetrical. It is round with flat contour. Nipples are brown, Lymph nodes are not palpable. M. Heart Adynamic Precardium, normal rate, regular rhythm, no murmur, full and equal pulses, Blood Pressure of 120/80, Pulse rate of 69. N. Chest and Lungs Lung shape is AP to lateral ratio of 1:2. Lung expansion is symmetrical as well as fremitus. Breathing pattern is regular and equal breath sounds. Respiratory rate of 19 cpm. O. Abdomen Abdomen has normal racial tone of brown. Abdomen is soft, Normoactive bowel sounds, non-tender. Movement is symmetrical. Bladder is not distended. Liver is not palpable. P. Upper Extremities For the upper extremities, motor strength is 2/5.he can move his arms from up, side and down and can shake is hands. No tenderness present and no deformities noted. Peripheral pulses are present, equal and normal. Lymph nodes are not palpable. Q. Lower Extremities For the lower extremities, motor strength is 2/5. He can move his legs up, side and down. Ha can also rotate his ankles. Lesions present at both legs. Peripheral pulses are present, equal and normal. Lymph nodes are not palpable. R. Genitalia No difficulty in urinating and defecating. Defecates once a day and urinates 5 to 7 times a day.