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PHYSICAL ASSESSMENT

AREA INSPECTION PALPATION AUSCULTATION PERCUSSION


Integument

Skin - Dark skin complexion - Presence of poor N/A


- Jaundice skin turgor
- Dryness - Warm to Touch
- Erythema

Hair - Black hair color - Thick and Silky N/A


- Evenly Distributed and
Variable amount of
body hair
Nails - Whitish nail beds - It is smooth and N/A
- Clubbing intact with the
epidermis
- When nails
pressed between
the fingers
( Blanch Test),
delayed return of
usual color for
more than 4
seconds
Head - Rounded, - There are no N/A
normocephalic and nodules or masses
symmetrical and depressions
when palpated
Eyes and Vision

Eyebrows - Hair is evenly


distributed
- Symmetrically aligned
and showed equal
movement when asked
to raise and lower
eyebrows

Eyelashes

- Equally distributed and


curled slightly outward

Eyelids - No presence of
discharges
- Lids close
symmetrically with
involuntary blinks
approximately 15-20
times per minute

- Jaundice

Eyes

Hearing
- Auricles are - Mobile, firm and
Ears symmetrical and has not tender
the same color with the - Pinna recoils when
facial skin folded
- Aligned with the outer
canthus of the eye
- Able to hear in both
ears
Nose and Sinus - Symmetric, straight - No tenderness and
and uniform in color lesions
- No presence of
discharge or flaring
Mouth - Pale and Dry lips - Rough Texture
- Purse his lips when
asked to whistle

Teeth and Gums - With dental caries and


decayed molars

Tongue and floor of - Central position, pink


the mouth but with whitish
coating which is
normal, with veins
prominent in the floor
of the mouth
Neck - Positioned at the No masses palpated
midline
Thorax and Lungs

Posterior Thorax
- Chest symmetrical - With normal breath
-Deep resonant sound
sounds (Broncho-
vesicular)

Anterior Thorax Quiet, rhythmic and Effortless breathing


effortless respiration
Abdomen - Uniform in color - Presence of - Hyperactive With 23 bowel Large dull areas
- Distended abdomen tenderness sounds/minute
with 96cm abdominal
girth
- Tense and glistening
skin
- Limited movement due
to pain
- Abdominal pain with a
pain scale of 10
Upper Extremeties - Without scars and -No tenderness
lesions on both
extremites
- Presence of Cyst on his
right thumb
- With ongoing IVF #5
PLR 1L at 650ml;
infusing well at 30
gtts/min at left
metacarpal vein via IV
cannula G#22
- With side drip bot #2
Dextamin 500cc at 450
cc level; infusing well at
31cc/hr
Lower Extremities - With minimal scars on -Pitting edema (3+ 6mm)
lower extremities

Muscles - Equal in size both sides - No masses


of the body palpated

Bones and joints - No deformities or


swelling
- Joints move smoothly