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PHYSICAL EXAMINATION

(Pre-physical exam)

1. General information • Pinkish mucosa


Name: Dela paz, Demetrio • Tender sinuses
Age: 58 y/o
Sex: Male 9. Mouth
Civil Status: Single • No dentures
Home address: 3821 PHAO, Pasig city • No teeth
• (-) lesions
2. Vital Signs
BP: 110/70 • Tongue in midline
Temp: 38.1 • Gums pinkish
RR: 32 • Uvula in midline
PR: 96 • Tonsils not inflamed
Wgt: 64.3 kg. • Moist buccal mucosa
Ht: 5”4
10. Neck
3. General Survey • Trachea in midline
• Conscious • Non-palpable cervical lymph nodes
• Coherent • Non-palpable thyroids
• Oriented to time and place • (-) neck enlargement
• Looks acc. to age • Normal ROM

4. Skin 11. Breast and Axillae


• (-) pallor • Equal size, symmetrical
• Skin dryness • (-) discharge, nipple masses
• Cracking lips • (-) edema, tenderness
• Warm skin temperature
12. Chest and Lungs
5. Head • AP ratio 1:2
• Normocephalic, symmetrical • Symmetrical chest expansion
• Fine hair, normal hair distribution • (-) wheezes, rales, rhonci
• (-) alopecia • (-) dullness
• (-) retraction
6. Eyes
• Lids symmetrical 13. Abdomen
• Smooth clear eye lenses • (-) scars
• Equal pupil size • (-) Murphy’s sign
• L,R pupil briskly reactive to light • (-) fluid wave
• Uniform constriction • (-) tenderness
• Normal visual acuity • Hyperactive bowel sounds
• Gallbladder not palpable
7. Ears
• Pinnae symmetrical 14. Back and extremities
• (-) foul smell, serous, purulent, • Peripheral pulse symmetrical, regular
mucoid, impacted cerumen • Pale nail beds
• Hearing Problem • (-) edema
• (-) delayed capillary refill
8. Nose
• (+) non healing wound (R foot)
• Symmetrical
• (+) weakness
• Septum in midline (-) perforation
• Both nares patent