Physical Examination

General Physical Survey

Assessed patient sitting on bed, conscious and coherent. With and an
attached nasal cannula giving oxygen. With an attached IV fluid on her right arm.
Patient appears to be in her late adolescence, with a cooperative attitude and
behavior. Her responses are appropriate and understandable. Her mood is relaxed.
She is dressed in a shirt and shorts. She has a lean body build, stands at a height of
5 feet and 1 inch and weighs 50 kilograms. Her BMI is 20.8 kg/m 2. She uses her
accessory muscles to breath but does not have difficulty in speaking
Her Vital Signs are as follows: Temperature= 37.3C; Heart Rate= 79
beats/min; Respiratory Rate: 34 cycles/min; Blood Pressure= 120/80 mmHg.

Skin, Hair, and Nail Assessment

General skin color is fair, texture is smooth and soft, warm and dry to touch
Turgor: pinched-up skin returns immediately to original position
No swelling, pitting or edema on extremities or abdomen
No detectable skin lesions on extremities and face
Hair is black and thick in amount and distribution, with fine texture. No
parasites present upon inspection
Scalp in symmetrical, smooth and firm with no lesion
Nails are round in shape hard and immobile. Nail beds are pink

Head and Neck Assessment

Face and facial features are symmetrical

Neck is smooth with no detectable lesions. With difficulty in moving the neck
Trachea is midline symmetrical
Thyroid is midline, smooth firm and non-tender
With non-palpable cervical lymph nodes

Eye Assessment

Lid margins are pink lashes are short, evenly spaced and curled outward
Blinking is symmetrical
Bulbar conjunctiva is clear with tiny visibles clears
Palpebral conjunctiva is pink with no discharge
Cornea is transparent, smooth and moist
Irises are both round and equal and black
Lacrimal apparatus mucosa is pink. No tenderness or discharge noted when
pressure is applied.

Peripheral Vision: client and examiner report seeing object at the same time
as it approaches from the periphery
Pupils converge and constrict as object moves in toward the nose; pupil
responses are uniform
Both eyes move in a smooth, coordinated manner in all directions
Reflections of light noted at the same location on both eyes
Direct pupil response: both illuminated pupils constrict
Consensual pupil response: pupil opposite the one illuminated constricts
simultaneously on both eyes
Cover-Uncover test: uncovered eye does not move as opposite eye is
covered, covered eye does not move as cover is moved. (both eyes)
Red reflex is round bright with red-orange glow on both eyes
Round optic disc with sharply defined margins
Retinal vessels are normal, regular in shape
Macula is darker than remainder of retina; fovea seen as a tiny bright light in
the center of macula

Ear Assessment

Both ears are positioned at the alignment of the pinna with corner of the eye
Skin is smooth, without nodules
External ear is non-tender upon palpation
Mastoid process is non-tender, warm and easily palpated
Cerumen is brown in color, waxy in consistency with no odor,
Canal walls are pink and uniform with tympanic membrane visible
Tympanic membrane is pearly gray, shiny and translucent. Intact and
landmarks are easily visualized
Patient is able to hear rubbing of fingers 1-2 feet from the ear
Romberg test: client stands straight with no swaying

Mouth, Throat, Nose and Sinus Assessment

Lips and surrounding tissue symmetrical and with smiling. No lesions,
swelling or drooping
Buccal mucosa is pink and without lesions
Gums are pink with clearly defined margins
Tongue is pink with papillae presents, symmetrical appearance with midline
fissure present. Movement is smooth and color is pink
Ventral surface of the tongue is pink. Frenulum is centered
Hard palate is pale in color and soft palate is pink in color
The oropharynx is pink in color with tonsils pillars without exudate. Uvula is
midline
Nose is same color as face and symmetrical. Nares are symmetrical, dry with
no crusting and septum is midline

Nares are patent. Air is felt on exhalation

Sinuses are non-tender on palpation
Thoracic and Lung Assessment

Chest is symmetrical
Respiration is regular, rapid with use of accessory muscles
No pain or tenderness on the thorax
Vocal fremitus is decreased
Symmetrical expansion of lungs
Resonance on percussion of the lungs
With normal breath sounds over lungs. No sounds of stridor, crackles or
wheezing

Breast Assessment

Did not assess as patient did not consent. But reported no lesion on both
breasts

Heart Assessment
no palpable thrill
Normal rate and rhythm
Radial and apical pulse are identical
Distinct heart sounds heard on all valves

Peripheral Vascular Assessment

Brachial, carotid, radial arteries palpable

Upper Extremities are fair in color, warm to touch. Patient can identify light
and deep touch, non-tender
Radial Pulses are strong and equal
No jugular vein distention on both sides of neck
No pain upon dorsiflexion of the foot

Abdominal Assessment
No rashes or lesions noted
Umbilicus is sunken and centrally located
Abdomen is flat and symmetrical
Normal Bowel sounds (high-pitched and irregular gurgles equally heard in all
four quadrants)
No bruits, no hums and friction rubs

Tympanic upon percussion over bowels

Abdomen is non-tender with no masses palpated on light and deep palpation
Liver is non-tender, smooth, firm sharp edge and no masses
Non-palpable spleen
No increase in abdominal girth
Genitourinary assessment
Not examined
Musculoskeletal Assessment

Stance: weight is evenly distributed, stands erect

Normal spinal curvature (cervical concave, thoracic convex, lumbar concave)
Full ROM in spine
Able to shrug shoulders against resistance. Shoulders non-tender
Shoulders, scapula and posterior hip: smooth, non-tender, no swelling. Equal
in size bilaterally, equally strong. Warm to touch
Head and neck: symmetrical, can open mouth without pain, full ROM
NecK: can turn head laterally against resistance without pain
Shoulder, Elbow, wrist and fingers: Symmetrical and full Rom
Arm: can flex and extend arm against resistance
Hand: grip is firm and equal, non-tender
Elbow, wrist, hand, finger: nontender, smooth, regular and equal bilaterally,
strong and non-tender
Hip, knee, ankle and foot: bilaterally symmetrical and equal, feet maintain
straight position. Bilateral leg length, full ROM

Neurologic Assessment

Patient is alert and awake with eyes open and looking at examiner; client
responds appropriately
Aware of self, others, place, time
CN I: identifies scent correctly with each nostril
III, IV, VI: Normal extra-ocular movements. Pupils equally round, and reactive
to light and accommodation
V: eyelids blink bilaterally. Identified light touch, dull and sharp sensations to
face
VII: identifies taste correctly
IX: taste is present, gag reflex present
X: Bilateral, symmetrical rise of soft palate and uvula
XI: able to shrug shoulders against resistance. Able to turn head against
resistance
XII: symmetrical tongue with smooth outward movement with bilateral
strength
Identifies light touch with cotton

Identifies and differentiates touch between sharp and dull sensations

Smooth accurate movements while touching finger to nose
Rapidly turns palms up and down
Patellar Reflex on both knees: +2
Babinski Reflex: (-)