V.

PHYSICAL ASSESSMENT
Vital Signs: BP 130/70mmHg
PR 86bpm regular
RR18cpm regular
T 36. !
Ht. 170cm" #t. 6.$%g" B&' ((.3 %g/m(
)eneral Sur*e+: c,nsci,us" c,-erent" ambulat,r+" ,riente. t, time" pers,n an. place/ ablet,
resp,n. appr,priatel+ t, 0uesti,ns" 1ell2gr,,me." mes,m,rp-ic b,.+
-abitus" spea%s in a n,rmal2pitc-e. *,ice" 1it- g,,. t-,ug-t pr,cess an.
appr,priate m,,. an. a33ect/ n,t c,m3,rtable
Re*ie1 ,3 S+stems:
o S%in: 1arm" m,ist" n, lesi,ns" n, acti*e .ermat,ses
o H445T:e+ebr,1s s+mmetrical" t-in an. e0uall+ .istribute." e+eli.s n,n2
e.amat,us"n, matting" n, .isc-arge" pin% palpebral c,n6uncti*ae" anicteric
sclerae" pupils (23mm e0uall+ reacti*e t, lig-t" e7tra,cular muscles 3ull an. e0ual
o 8un.,sc,p+: 9:;re. ,range re3le7" clear .isc margin 1it- <V rati,(:3" n,
e7u.ates" n, -em,rr-ages" n, .e3,rmities" n, masses" n, lesi,n" n, ten.erness"
n,n2-+peremic e7ternal au.it,r+ canal" n, 3,reign b,.ies. 47ternal n,se
s+mmetrical" nasal septum mi.line" n, ,bstructi,n" n, masses" n, lesi,ns" n,
c,ngesti,n
o =ips an. gums pin%is-" buccal muc,sa .r+" pin% 3renulum lingua" pin% -ar.
palate" t,ngue mi.line
o 5ec%: m,bilit+ n, limitati,n ,3 m,ti,n" n, l+mp-a.en,pat-ies" n, t-+t,i.
enlargement" n, ,t-er masses
o Respirat,r+: n, .e3,rmities ,n anteri,r c-est"anter,p,steri,r .iameter smaller
t-an lateral .iameter" s+mmetriclal c-est e7pansi,n" e0ual tactile 3remiti/ all lung
3iel.s res,nant ,n percussi,n" e0ual *,cal 3remiti. 5,rmal breat- s,un.s ,n b,t-
lung 3iel." n, 1-ee>es" crac%les
o !ar.i,*ascular: nec% *eins n,t .isten.e." ?VP cm at $ .egrees angle" car,ti.
pulse:( amplitu.e 1it- rapi. upstr,%e an. gra.ual .,1nstr,%e. @+namic
prec,r.ium <B at 6
t-
le3t '!S <<=" n, -ea*es" n, t-rills" n, li3ts" s1As( at ape7"
s(As1 at base" n, murmurs
o Pulses: car,ti." brac-ial" ra.ial" 3em,ral" p,pliteal" .,rpe.is" p,st tibial are all
n,rmal R=
o )astr,2intestinal:s+mmetrical" 3lat ab.,men" n, *isible pulsati,ns" n, *isible
peristalsis" n,rm,acti*e b,1el s,un.s/ all 0ua.rants t+mpanitic" n, ten.erness ,n
lig-t an. .eep palpati,n" n, masses" li*er span 8cm" spleen n,t palpable
o )enit,2urinar+:n, ten.erness" %i.ne+s n,t palpable
o &uscul,s%eletal: n, lesi,ns"n, .e3,rmities" n, cac-e7ia" n, ten.erness" n, e.ema"
n, clubbing
o 5eur,l,gical: mental status2 c,nsci,us" c,-erent" ,riente. t, time place an.
pers,n" 3,ll,1s *erbal c,mman.s" recent an. rem,te mem,r+ intact"
)!S1$9e*$m6;/ cranialner*es2 12 n, an,smia" (2pupils (23mm 4RT=" 9:;.irect
an. c,nsensual lig-t resp,nse" 3$23ull an. e0ual" n, pt,sis" $2n, sens,r+ .e3icits"
can clenc- teet-" can c-e1 1it- ease" 72can raise e+ebr,1s" can smile" can pu33
c-ee%s" 82gr,ss -earing intact" B"102u*ula mi.line" can s1all,1 1it- ease" 112can
raise s-,ul.ers against resistance" 1(2t,nguemi.line ,n pr,trusi,n"
&CTCR:manual muscle testing sc,res $/$ ,n all e7tremities" !,,r:can per3,rm
3inger t, n,se test an. -ell t, s-in test" )ait: n,t assesse." Sens,r+: n, gr,ss
sens,r+ .e3icits" Re3le7es @TRS n,rmal ,n all e7tremities" &eningeal signs: n,
nuc-al rigi.it+" n, bra.>in%iDs" n, %ernigDs
HEAD-TO-TOE ASSESSMENT
Body Part Method of
Assessment
Normal
Findings
Actual
Findings
Interpretatio
n & Analysis
Skn Inspecton Skn s
unform
whtsh pnk or
brown coor
No Beedng
No area of
Skn s pae
(paor)
No beedng
Skn may be
pae because
of nsumcent
oxygen suppy.
Papaton
ncreased
vascuarty and
ecchymoss
No skn
esons present
except for
freckes,
brthmarks or
moes whch
may be at or
eevated
Skn s dry
wth a
mnmum of
perspraton.
Warm and
equa
bateray.
Hands and
skn sghty
cooer than the
rest of the
body
Skn surfaces
non-tender
Texture:
Smooth,
even and rm
except where
there s
sgncant har
growth
Skn turgor:
When
reeased,
shoud return
to orgna
contour rapdy
No area of
ncreased
vascuarty and
ecchymoss
No esons
Warm and
equa
bateray
Edema not
present
Skn sprung
back rapdy
when pnched
No edema
present
Scap and Har Inspecton Dark back to
pae bonde;
may turn gray
or whte; may
be chemcay
changed
Termna har
found n the
eyebrows,,
eyeashes, and
scap, and n
axa and
pubc areas
after puberty.
No sgns of
nfestaton or
esons.
Seborrhea/
dandruh may
be present
Har may fee
thn, straght,
coarse, thck
or cury. Shny
and resent
Har appears
back wth
some whte
har due to
agng.
Even
dstrbuton of
har
No
nfestaton or
esons
No sgncant
ndngs
Papaton
Har s thck
and shny
Nas Inspecton
Papaton
Have a pnk-
cast n ght-
sknned and
brown n dark-
sknned.
Capary
re present
(shoud return
to norma 2-3
sec)
Surface s
smooth, and
sghty
rounded or
at. Curved
nas are
norma.
Unform na
thckness
throughout; no
spnterng or
brtte edges.
Ange
approx. 160
Frm na
base
Capary
re of ess
than 2 seconds
Surface
smooth and
sghty
rounded
No spnters
or brtte edges
Ange
approx. 160
Frm na
base
No sgncant
ndngs
Eyes Inspecton Symmetrca Eyes No sgncant
wth no
droopng,
nfecton,
tumors or
other
abnormates
Vsua Acuty:
20/20
Scera:
Whte n ght-
sknned w/o
exudates,
esons or
foregn bodes.
In dark-
sknned, may
have brown
patches
Pups:
equay round,
reactve to
ght and
accommodato
n; 2-6 mm
No tearng,
sweng or
dscharge
symmetrca
Scera
appears whte
Pups equay
round, reactve
to ght and
accommodato
n; approx. 4
mm
No tearng,
sweng or
descharge
ndngs
Ears Inspecton Match esh
coor of the
rest of the
skn.
Centra
Same coor
as face
Centra
No sgncant
ndngs
Papaton
poston.
Proportona.
No redness,
esons,
sweng,
tenderness
Shoud not
compan of
pan or
tenderness
poston
Proportona
No redness,
sweng, or
tenderness
No pan
assessed
Nose Inspecton
Papaton
Symmetrca,
mdne of the
face.
Wthout
sweng,
beedng,
esons, or
masses.
Each nostr
patent.
No pan or
dscomfort
durng
papaton
Symmetrca
and n mdne
No sweng,
beedng,
esons, or
masses
Wth nasa
arng.
No pan or
dscomfort
noted
No sgncant
ndngs
Ths may be
due to
dmcuty of
breathng and
chest pan.
Mouth Inspecton Breath smes
fresh.
Lps and
membranes
pnk and most
wth no esons
or
Lps and
membranes
are most, dark
esh coored;
No sgncant
ndngs
nammaton.
Tongue s
mdne. Pnk,
most, rough
wthout
esons.
Symmetrca;
moves freey.
Gums have
pae-red
strpped
surface.
No sweng
or beedng.
no esons or
nammaton
Tongue n
mdne and
moves freey

No sweng
or beedng
Neck Inspecton
Papaton
Symmetrca
wth head n
centra
poston. Abe
to move head
wthout
dscomfort or
notceabe
mts
Musces
shoud be
symmetrca
wthout
papabe
masses or
spasm
Symmetrca
wth head n
centra
poston
Abe to move
head w/o
dscomfort
No papabe
masses
No sgncant
ndngs
Chest Inspecton Wthout
esons; skn
ntact.
Ouet,
rhythmc and
Wthout
esons
Ouet
Ths s due to
chest pan and
Papaton
Auscutaton
ehortess
breathng
No
pusatons,
masses,
thoracc
tenderness
present.
Norma ung
tssue
produces
resonant
sound,
daphragm has
du sounds.
Broncha,
bronchovescu
ar or vescuar
breath sounds
rhythmc and
ehort on
breathng
No masses or
tenderness
cardomegay.
Abdomen Inspecton
Auscutaton
Abdomna
contour at or
rounded.
Symmetrca.
Unform n
coor or
pgmentaton.
No
abdomna
scars.
No strae
Intermttent
gurgng
sounds
throughout
abdomna
quadrants.
Abdomna
contour
rounded.
Symmetrca.
Unform n
coor.
No scars;
strae
Gurgng
No sgncant
ndngs
Percusson
Papaton
Tympany,
predomnant
sound heard
No organ
enargement
papabe, or
any masses,
buges, or
sweng
sounds n
abdomen


No frcton
rubs/ audbe
bruts
Suprapubc
Area
Inspecton
Papaton
Wthout
esons
Urnary
badder not
papabe and
not tender
Wthout
Lesons
Urnary
badder not
papabe
No sgncant
ndngs
Upper
Extremtes
Inspecton Wthout
esons, scars
or
nammaton
Wthout
esons, scars
or
nammaton
No sgncant
ndngs
Lower
Extremtes
Inspecton
Papaton
Wthout
esons, scars
No edema
Wthout
esons, scars
No edema
No sgncant
ndngs
CONTRAPTURES:
NONE (The patient is f! "is#ha!$e%