PHSYICAL EXAMINATION GENERAL INFORMATION Name: MS. M.B.

Age: 44 YEARS OLD Date: MARCH 14,2012 Unit: ROOM 212 2ND FRONT Examiner: MILCAH CASTILLO CC: PAIN ON LEFT BREAST MULTIPLE BREAST MASS (L) Admitting Diagnosis: MULTIPLE BREAST MASS (L) VITAL SIGNS VITAL SIGNS Temperature (Oral, axilla, rectal) Pulse Rate Heart / Cardiac Rate Respiratory Rate Blood Pressure TECHNIQUE USED INSPECTION INSPECTION INSPECTION INSPECTION ASCULTATION 78 78 21 110/80 ACTUAL FINDING 36.3 SIGNIFICANCE NORMAL NORMAL NORMAL NORMAL NORMAL

I GENERAL SURVEY Height Wieght General Appearance TECHNIQUE USED INSPECTION INSPECTION INSPECTION ACTUAL FINDING 55 130 lbs ( ) no sign of distress ( ) With sign of distress ( ) Cardio Respiratory ( ) pain ( ) Conscious ( ) Drowsy ( ) Comatose ( ) Others () Coherent ( ) Incoherent ( ) Others ()Oriented ( ) Disoriented Time ____ Place ____Person_______ NORMAL. NORMAL. NORMAL. SIGNIFICANCE

Level of consciousness

INSPECTION

Coherence

INSPECTION

NORMAL. TO IDENTIFY IF THE PATIENT IS STILL AWARE OF HER ENVIRONMENT. NORMAL.

Orientation

INSPECTION

NORMAL.

Development

INSPECTION

Nutrition

INSPECTION

Emotional State

INSPECTION

() Endomorph / Well developed ( ) Mesomorph / Fairly developed ( )Ectomorph / Poorly developed ( ) Looks According to Age ( ) Appears older/ younger than stated Age ( ) Well Nourished ( ) Obese ( ) Cachexic () Calm ( ) Tense ( )Worried ( ) Restless ( ) Others _____________________

NORMAL.

NORMAL.

NORMAL.

II SKIN General Color TECHNIQUE USED INSPECTION ACTUAL FINDING ( ) Pinkish ( ) Pallor ( ) Jaundice ( ) Flushed ( ) Cyanotic ( ) Others _________ ( ) Smooth ( ) Rough ( ) Others _________________ () Good ( ) Fair ( ) Poor ( ) Warm ( ) Cool ( ) Others______________ () Dry ( ) Wet ( ) Clammy ( ) Oily SIGNIFICANCE NORMAL.

Texture

INSPECTION

NORMAL.

Turgor

INSPECTION

NORMAL.

Temperature

INSPECTION/PALPATION

NORMAL.

Moisture

INSPECTION

NORMAL. TO IDENTIFY IF PATIENT HAS DRY SKIN.

III HEAD Configuration TECHNIQUE USED INSPECTION ACTUAL FINDING ( ) Normocephalic ( ) Masses NORMAL. SIGNIFICANCE

Hair

INSPECTION

Scalp

INSPECTION

Lids

INSPECTION

( ) Other () Fine ( ) Coarse ( ) Dry ( ) Normal / Even Distribution ( ) Alopecia ( ) Clean ( ) Dandruff ( ) Lice ( ) Wounds / Scars / Lesions () Symmetrical ( ) R/L Edema / Swelling ( ) R/L Ptosis ( )Non Edematous ( ) Sunken ( ) Discoloration ( ) Pink ( ) Pale ( ) Lesion ( )Discharge () Anecteric ( ) Subicteric ( ) Ecteric ( ) Hemorrhage ( ) Smooth ( ) Clear ( ) Lesion ( ) Opacity ( ) Arcus Senilia () Equal ( ) Unequal R: __3___mm R: () Brisk ( ) Sluggish ( ) Fixed

NORMAL.

NORMAL.

NORMAL. TO IDENTIFY THE SYMMETRY OF LIDS.

Periorbital region

INSPECTION

Conjunctiva

INSPECTION

NORMAL. TO IDENTIFY IF THE PATIENT DEVELOPED EDEMA ON PERI ORBITAL REGION. NORMAL. PALE CONJUNCTIVA MAY INDICATE ANEMIA.

Sclera

INSPECTION

NORMAL.

Cornea and Lens

INSPECTION

NORMAL. TO IDENTIFY IF THE CORNEA AND LENS OF THE PATIENT HAS ANY INJURY NORMAL. TO IDENTIFY IF BOTH PUPILS HAS THE SAME SIZE NORMAL. TO IDENTIFY IF THE PUPIL CAN NORMALLY REACT TO LIGHT. NORMAL. TO IDENTIFY IF THE PUPIL CAN CONSTRICT WHEN AN OBJECT IS NEAR AND IF IT CAN DILATE IF AN OBJECT IS

Pupil Size

INSPECTION

L: __3___mm L: ( ) Brisk ( ) Sluggish ( ) Fixed

Reaction to Light

INSPECTION

Reaction to Accommodation

INSPECTION

( ) Uniform constriction ( ) Unequal constriction

AWAY FROM THE EYES. Convergence INSPECTION () Intact ( )Others __________ () Gross Normally ( ) Farsighted ( ) Nearsighted NORMAL. CONVERGENCE BECOMES SLUGGISH WITH AGING AND TRAUMA.

Visual acuity

INSPECTION

IV EARS External Pinnae TECHNIQUE USED INSPECTION ACTUAL FINDING ( ) Normoset ( ) Symmetrical ( ) Gross Abnormality ( ) Tenderness ( ) Clean SIGNIFICANCE NORMAL. TO IDENTIFY IF THE PATIENT HAS A NORMAL EXTERNAL PINNAE AND TO IDENTIFY IF IT IS SYMMETRICAL. NORMAL. TO IDENTIFY ANY DISCHARGE PRESENT IN THE EXTERNAL CANAL OF PATIENT. NORMAL. DISCHARGE INDICATES BLOCKAGE OF EAR CANAL OR INFECTION NORMAL. TO IDENTIFY IF THE PATIENT CAN HEAR ON BOTH EARS.

External Canal

INSPECTION

Discharge

INSPECTION

NONE

Gross Hearing

INSPECTION

() Symmetrical ( ) R / L Deafness

V NOSE Nasolabial Fold TECHNIQUE USED INSPECTION ACTUAL FINDING ( ) Symmetrical ( ) R / L Shallow nasal fold () Midline ( ) Deviated ( ) Perforation ( ) Pinkish ( ) Pale SIGNIFICANCE NORMAL. TO IDENTIFY IF THE PATIENT HAS A SYMMETRICAL NASO LABIAL FOLD. NORMAL. TO IDENTIFY IF THE SEPTUM IS IN THE MIDLINE. NORMAL. PALSE MUCOSA MAY INDICATE

Septum

INSPECTION

Mucosa

INSPECTION

( ) Reddish Discharge INSPECTION NONE

ANEMIA. NORMAL. TO IDENTIFY IF THERE IS PRESENCE OF DISCHARGE. NORMAL. TO IDENTIFY THE PATENCY OF THE NARES OF THE PATIENT. IF BOTH NARES CAN SMELL SYMMETRICALLY. NORMAL. TO IDENTIFY IF THE PATIENT CAN IDENTIFY DIFFERENT SMELL. NORMAL. TENDER SINUSES MAY INDICATE SINUSITIS.

Patency

INSPECTION

( ) Both Parent ( ) R / L Obstructed exhalation

Gross Smell

INSPECTION

( ) Symmetric ( ) R/L Olfactory Deficiency ( ) Non tender ( ) Tender

Sinuses

INSPECTION

VI MOUTH Lips TECHNIQUE USED INSPECTION ACTUAL FINDING ( ) Pinkish ( ) Cyanosis ( ) Dryness / Crackles ( ) Lesion ( ) Midline ( ) R/ L Deviation ( ) Atrophy ( ) Fasciculation ( ) Complete ( ) Missing teeth ( ) Carries ( ) Denture ( ) Braces / Retainers Specify ______________ ( ) Pinkish ( ) Pallor ( ) Bleeding ( ) Pinkish ( ) Pallor ( ) Cyanotic SIGNIFICANCE NORMAL. PALE LIPS MAY INDICATE ANEMIA.

Tongue

INSPECTION

NORMAL. TO IDENTIFY IF THE PATIENTS TONGUE IS IN THE MIDLINE. TO IDENTIFY IF THE PATIENT USES DENTURES.

Teeth

INSPECTION

Gums

INSPECTION

NORMAL. PALE GUMS MAY INDICATE ANEMIA. NORMAL. PALE MUCOSA MAY INDICATE ANEMIA.

Mucosa

INSPECTION

Speech

INSPECTION

( ( ( (

) Intact ) Slurred )Aphasic ) Others _____________

NORMAL. TO IDENTIFY IF THE PATIENT HAS AN INTACT SPEECH.

VII PHARYNX Uvula TECHNIQUE USED INSPECTION ACTUAL FINDING ( ) Midline ( ) R / L Deviation ( ) Pinkish ( ) Pallor ( ) Reddish ( ) Not Inflamed ( ) R / L Inflamed ( ) R / L With exudates SIGNIFICANCE NORMAL. TO IDENTIFY IF THE UVULA IS PRESENT AND IF IT IS IN THE MIDLINE. NORMAL. PALE MUCOSA MAY INDICATE ANEMIA. NORMAL. INFLAMMED TONSILS MAY INDICATE TONSILITIS.

Mucosa

INSPECTION

Tonsils

INSPECTION

VIII NECK Trachea TECHNIQUE USED INSPECTION ACTUAL FINDING ( ) Midline ( ) R / L Divation ( ) Non palpable ( ) Palpable ( ) Tender ( ) Non palpable ( ) Enlarge SIGNIFICANCE NORMAL. TO IDENTIFY IF THE TRACHEA IS ON ITS LOCATION. NORMAL. PALPABLE LYMP NODES MAY INDICATE PRESENCE OF INFECTION NORMAL. TO IDENTIFY IF THE THYROID IS PALPABLE OR NOT. PALPABLE THYROID MAY INDICATE HYPERTHYROIDISM. NORMAL.

Cervical lymph nodes

INSPECTION

Thyroid

INSPECTION

Others

INSPECTION

( ) Normal ROM ( ) Neck rigidity ( ) Neck vein engorgement visible Upright ( ) Masses

IX CHEST AND LUNGS Inspiration / Exhalation Ratio TECHNIQUE USED INSPECTION 1:1 ACTUAL FINDING SIGNIFICANCE NORMAL. TO IDENTIFY IF THE PATIENTS EXHALATION AND INHALATION RATIO IS NORMAL. NORMAL. TO IDENTIFY IF THE PATIENT HAS DIFFICULTY OF BREATHING.

Breathing Pattern

INSPECTION

Shape of Chest: Anterior Posterior Lateral Ratio

INSPECTION

( ) Regular (Eupnea) ( ) Effortless ( ) Hyperpnea ( ) Tachypnea ( ) Dsypnea ( ) Uses of accessory muscle ( ) Other ___________ AP _____1______ L ____2________ ( ) Barrel chest ( ) Funnel ( ) Pigeon ( ) Others _______________ ( ) Symmetrical ( ) R/ L Decreased / Lag ( ) Symmetrical ( ) Decreased / Increased at _____

NORMAL. ANTERIOR POSTERIOR LATERAL RATIO MAY INDICATE THE SIZE OF THE CHEST OF THE PATIENT. TO IDENTIFY IF THERE IS ANY ABNORMALITIES. TO IDENTIFY IF THE PATIENTS LUNGS CAN EXPAND SYMMETRICALLY. NORMAL. TO IDENTIFY THE PATIENTS TACTILE FREMITUS IS SYMMETRICAL. NORMAL.THE LUNGS IS FILLED

Lung Expansion

INSPECTION

Vocal/ Tactile Fremitus

PALPATION

Percussion

PERCUSSION

( ) Resonant at lung fields

Breath Sounds

AUSCULTATION

( ( ( ( ( ( ( ( ( (

) Dullness at _______________ ) Hyper-resonant at _________ ) Liver Dullness at __________ ) Spleen Dullness at ________ ) Bronchial at ______________ ) Bronchovesicular at ________ ) Vesicular at ______________ ) Crackles at ______________ ) Wheezing at _____________ ) Pleural friction rub _________

WITH AIR.

NORMAL. THE PATTERN OF NORMAL BREATH SOUNDS ARE CREATED BY THE EFFECT OF BODY STRUCTURES ON AIR MOVING THROUGH AIRWAYS.

X HEART Precordial TECHNIQUE USED INSPECTION ACTUAL FINDING ( ) Flat ( ) Bulging ( ) Tenderness ( ) Heave ( ) Thrill ( ) Normo-dynamic pre cordium At 5TH intercostal space Apical beat at midclavicular line ( ) Distinct ( ) Regular ( ) Faint ( ) Irregular S1 __________ S2 at the base S1 __________ S2 at the apex Others: ( ) S3 ( ) S4 ( ) Murmurs best heard at ____________ SIGNIFICANCE NORMAL. TO IDENTIFY IF THE PATIENT HAS PRESENCE OF BULGING IN THE PRECORDIAL AREA.

Point of Maximum Impulse

AUSCULTATION

NORMAL. TO IDENTIFY THE LOCATION OF PMI. NORMAL. TO IDENTIFY IF THERE IS PRESENCE OF ABNORMAL HEART SOUNDS.

Heart Sounds

AUSCULTATION

XII BREAST AND AXILLAE TECHNIQUE USED ACTUAL FINDING SIGNIFICANCE

Size

INSPECTION

( ) Equal ( ) Unequal ( ) Symmetric ( ) Asymmetric ( ) Pinkish ( ) Straic ( ) Blue Hue ( ) Increased vein engorgement ( ) Smooth ( ) Retraction ( ) Dimpling ( ) Edema ( ) Lesions ( ) Tenderness ( ) Masses at right side ( ) Others at _____________

NORMAL. TO IDENTIFY IF THE SIZE OF THE BREAST IS SYMMETRICAL. NORMAL. TO IDENTIFY IF THE SHAPE OF THE BREAST IS SYMMETRICAL. NORMAL. TO IDENTIFY IF THE COLOR OF THE BREAST AREA IS THE SAME AS COLOR OF THE PATIENTS BODY. It has multiple breast mass on the left side. She was advice to undergo surgery.

Shape

INSPECTION

Color

INSPECTION

Surface

INSPECTION

XII ABDOMEN General TECHNIQUE USED INSPECTION ACTUAL FINDING Smooth without lessions SIGNIFICANCE NORMAL. TO IDENTIFY IF THERES PRESENCE OF ANY INJURIES. NORMAL. TO IDENTIFY IF THE CONFIGURATION IS SYMMETRICAL.

Configuration

INSPECTION

Bowel Sounds

AUSCULTATION

( ) Symmetrical ( ) Asymmetrical ( ) Flat ( ) Globular ( ) Protuberal ( ) Scaphoid ( )Normoactive ( ) Hyperactive ( ) Hypoactive ( ) Absent

NORMAL. TO IDENTIFY IF THE PATIENT HAS BOWEL SOUNDS. ABSENCE OF BOWEL SOUND MAY INDICATE UNDERLYING DISEASE LIKE CONSTIPATION.

Percussion

PERCUSSION

( ) Tymphanic ( ) Hyperthmphanic

Palpation Tenderness

PALPATION INSPECTION

( ) Fluid wave ( ) Shifting dullness NONE NONE

NORMAL. NORMAL.

XIV
BACK AND EXTREMITIES Extremities: Peripheral Pulses TECHNIQUE USED INSPECTION ACTUAL FINDING ( ) Symmetrical ( ) Regular ( ) Absent ( ) Warm ( ) Faint ( ) Weak ( ) Strong ( ) Pounding ( ) Pinkish ( ) Pallor ( ) Cyanosis ( ) Inflammation ( ) Clubbing ( ) Delayed capillary refill ( ) Blanching ( ) Full ( ) Symmetrical ( ) Decreased ROM upon __________ ( ) Tenderness / Pain SIGNIFICANCE NORMAL. TO IDENTIFY THE PRESENCE OF PERIPHERAL PULSES IN THE BODY.

Nails and Nail Beds

INSPECTION

NORMAL. TO IDENTIFY THE CAPILLARY REFILL AND TO IDENTIFY ALSO THE COLOR OF THE PATIENT IS EVENLY DISTRIBUTED ON BOTH UPPER AND LOWER EXTREMITIES. NORMAL.

Range of Motion

INSPECTION

Muscle Tone and strength

INSPECTION

( ) Joint swelling ( ) Equally strong ( ) Symmetrical in muscle size ( ) R / L; Upper / Lower weakness ( ) Atrophy ( ) Midline ( ) Kyposis ( ) Lordosis ( ) Scoliosis ( ) Coordinated ( ) Smooth ( ) Uncoordinated ( ) Staggering ( ) Shuffling ( ) Stumbling

MUSCLE TONE AND STRENTH MAY INDICATE RESTLESNESS ON THE EXTREMITIES. NORMAL. TO IDENTIFY IF THE SPINE IS IN THE MIDLINE. NORMAL

Spine

INSPECTION

Gait

INSPECTION

XV NEUROLOGICAL ASSESSMENT Motor Response (Adult) TECHNIQUE USED INSPECTION ACTUAL FINDING ( ) 6 Obeys command ( ) 5 Localized pain ( ) 4 Flexion-Withdrawal ( ) 3 Flexion Abnormal ( ) 2 Extension ( ) 1 No response ( ) 4 Spontaneous ( ) 3 To verbal command ( ) 2 To pain ( ) 1 No response NORMAL. SIGNIFICANCE

Eyes Open

INSPECTION

NORMAL.

Verbal Response

INSPECTION

( ) 5 Oriented and Converses ( ) 4 Disoriented and Converses ( ) 3 Inappropriate word ( ) 2 Incomprehensible sound ( ) 1 No response ( ) 4 Spontaneous ( ) 3 To verbal command ( ) 2 To pain ( ) 1 No response ( ) 5 Coos Babbles ( ) 4 Irritable Cry ( ) 3 Cries to pain ( ) 2 Moves to pain ( ) 1 No response

NORMAL.

Eyes Open

INSPECTION

NORMAL.

Verbal Response

INSPECTION

NORMAL.