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Physical Assessment

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Physical Assessment
Mental Status: My patient is alert and knows his orientation. He is coherent and is able to recall recent and remote events. He appears healthy and shows no signs of distress or anxiety.
Skin & Nails: His skin appears to be tanned in color. There is no bleeding or a rash present but has a dime size contusion on right bicep. No signs of puffiness or pitting on the skin. The skin has a smooth texture with a warm touch and doesn’t appear too dry or moist. Patient doesn’t show any signs of dehydrations which means turgor is great along with skin mobility. The nails are pink in color and well cleaned. The branch test shows great capillary refill and no signs of nail clubbing and has an angle of 150 degrees.
Head: The patient’s hair is brown with little gray in it. No signs of hair loss and appears clean and shiny. He has no lesions, lice, or lumps present. The scalp appears to have normal distribution of hair on it. Face shows symmetry with appropriate facial movements and CN VII is intact. The patient has sensation in all six locations which indicates CN V is intact. The contraction of the masseter and temporal muscle feel normal and appear symmetrical and has no signs of temporomandibular joint disorder.
Neck: The patient had no difficulties completing range of motion. He has no masses/scars present and symmetry appears great. All nodes feel within normal range and no signs of swelling or inflammation. The trachea is mid-line, thyroid gland is normal without masses, and no goiter. Patient has no problems with trapezius and sternocleidomastoid muscle strength and CN XI appears to be intact as well.

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