PHYSICAL ASSESSMENT

DATE ASSESSED September 28, 2017 @ 8:00 am

INITIAL VITAL SIGNS Blood pressure 100/70 mmHg
Temperature 36.1 °C
Pulse rate 104 bpm
Respiratory rate 21 cpm
GENERAL APPEARANCE The patient was assessed lying on his bed with an
IVF line on his right hand. She was well-groomed
and has a good personal hygiene as manifested by
her odor of her body and breath. The patient had a
very pleasant facial expression. He welcomed the
examiner very well and answered the questions
without any apprehensions. The patient could still
converse and listen well, had a good comprehension
and level of consciousness.
AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL ANALYSIS INTERPRETA-
USED FINDINGS TION

SKIN
 Color Inspection Light brown, tanned sin Tanned Skin Normal
(According to race)

 Color Uniformity Inspection Generally uniform Generally uniform Normal

except in areas exposed
to sun
 Edema Inspection No edema noted Normal
Palpation No edema

 Temperature Palpation 36.1°C Normal

Normally warm to touch
 Texture Palpation Smooth, soft, and Normal
Inspection Smooth, soft and flexible palms and
flexible palms and soles soles (thicker)
(thicker)
 Turgor Palpation Springs back to Normal
previous state
Springs back to previous (1-2 seconds)
state
 Moisture Inspection (1-2 seconds) Skin normally dry Normal
Palpation
Skin Normally Dry
NAILS
 Nail plate shape Inspection Convex curvature; angle Convex curvature; Normal
between nail and nail angle between nail
bed is about 160 and nail bed is about
160

 Texture Palpation Smooth Smooth Normal

Inspection

 Color of nail bed Inspection Pinkish Pinkish Normal

 Nail base Inspection Firm Firm Normal

 Capillary refill Inspection White color of nail bed White color of nail Normal
Palpation under pressure should bed returned within
(Blanch Test) return within 2-3 2-3 seconds
seconds
 Tissue surrounding Inspection Intact epidermis Normal
nails Intact epidermis
 HAIR
 Color Inspection Varies from races, Black Normal
usually black among
Filipinos

 Hair Strands Inspection Thick hair strands Thick hair strands Normal

 Distribution Inspection Evenly distributed Evenly distributed Normal

 Texture Inspection/ Smooth Smooth Normal

Palpation

HEAD
 Scalp Symmetry Inspection Symmetrical Symmetrical Normal

 Skull Shape Inspection Round Round Normal

 Nodules and Inspection, Absence of nodules and No nodules and Normal

masses Palpation masses masses

FACE
 Symmetry Inspection Symmetrical symmetrical Normal

 Texture Palpation Smooth Smooth Normal

 Facial Movements Inspection Symmetric Facial Symmetrical Normal

movement movement

 Color Inspection Same as body color Light brown Normal

 EYES
 Position Inspection Symmetric position Symmetric Normal
position

 Conjunctiva Inspection Transparent with light Transparent with light Normal

pink color pink color

 Eyebrows Inspection Hair evenly distributed, Hair evenly Normal

skin intact, symmetric distributed, skin intact,
alignment symmetric alignment

 Eyelashes Inspection Distributed evenly and Distributed evenly and Normal

curved outward curved outward

 Cornea Inspection Transparent, shiny Transparent, shiny Normal

 Upper eyelids Inspection Skin intact, no discharges Skin intact, no Normal

and lesions discharges and lesions

 Pupils Inspection Color black, pupils Color black, pupils Normal

(PERRLA) constrict when light constrict when light
passes through passes through

 Pupil size Inspection 2-3 mm 2-3 mm Normal

 Upper and Lower Inspection Skin intact, No lesions, Skin intact, No Normal
eyelids same color as the skin lesions, same color as
the skin

 Sclera Inspection White White Normal

 Iris Inspection Clearly Visible Clearly Visible Normal

 EARS
 Auricle Inspection Symmetric position Symmetric position Normal

 Symmetry Inspection Symmetrical Symmetrical Normal

 Size Inspection The same with both sides The same with both Normal
sides

 Texture, elasticity Palpation Mobile, firm and not Firm and no Normal
and areas of tender; pinna recoils after tenderness
tenderness it is folded

 Ear Canal opening Inspection Free of lesions, discharge Free of lesions, Normal
or Inflammation discharge or
inflammation

 Hearing Acuity Inspection Client normally hears Client normally hears Normal
words when whispered words when
whispered

NOSE
NOSE
 Shape, size and skin Inspection Smooth, symmetric with Smooth, symmetric Normal
color same color as the face with same color as the
face

 Nasal septum Inspection Close to midline, thicker Close to midline, Normal

anteriorly than thicker anteriorly than
posteriorly posteriorly

 Tenderness, masses or Palpation No tenderness and No tenderness and Normal

displacements of lesions lesions
bones and cartilage

 Cilia, hair Inspection Evenly distributed Evenly distributed Normal

 Nares Inspection Oval, symmetric and Oval, symmetric and Normal

without discharge without discharge
 MOUTH AND PHARYNX
Due to
 Lips Inspection Pinkish, moist, Pale, dry, symmetrical Not normal mild
symmetrical dehydration
Glistening pink,
 Buccal Mucosa Inspection Glistening pink, soft,moist Normal
soft,moist
Pinkish, symmetrical,
 Tongue Inspection Moist, slightly rough on moist and no lesions Normal
dorsal surface medium or
dull red
Slightly pink, moist
 Gums Inspection Slightly pink, moist and and tightly fit against Normal
tightly fit against each each tooth
tooth
Hard palate-dome
 Hard And soft palate Inspection Hard palate-dome shape shape Normal
Soft palate- light pink Soft palate- light pink

TEETH
 Teeth Inspection Firmly set, shiny, no Firmly set, shiny, no Normal
tooth decay tooth decay
 NECK
 Symmetry of neck Inspection Neck is slightly Neck is slightly Normal
muscles, alignment of hyper extended hyper extended
trachea

 Movement Inspection Neck moves Neck moves Normal

freely freely

 Neck muscles for size, Inspection, Palpation Muscles equal in Muscles equal Normal
swelling or masses size; no swelling in size; no
or masses swelling or
masses

 Neck range of motion Inspection Neck moves Neck moves Normal

freely, without freely, without
discomfort discomfort

 Lymph nodes Palpation Not Palpable Not Palpable Normal

 Thyroid gland Palpation Rises freely with Rises freely Normal

swallowing with
swallowing

 Trachea Inspection Midline Midline Normal

 Symmetry Inspection Symmetrical Normal Normal

 THORAX AND LUNGS
 Respiratory movement Inspection Even movement Even Normal
Occurs in movement
respiration Occurs in
respiration

 Thorax and Lungs Auscultation Clear Breath Clear Breath Normal

Sounds Sounds

 Contour Inspection Almost round in Almost round Normal

adults, expands in adults,
bilaterally expands
bilaterally

(POSTERIOR THORAX)
 Color Inspection Same as body Brown Normal
color

 Texture Palpation No nodules/ No nodules/ Normal

lesions lesions

 Symmetry of chest Palpation Symmetrical Symmetrical Normal

expansion

(ANTERIOR THORAX)
 Breathing Pattern Inspection Quiet, rhythmic Quiet, rhythmic Normal
and effortless and effortless

 Symmetry Inspection Symmetrical Symmetrical Normal

 Color Inspection Same as body Brown Normal

color
 ABDOMEN
ABDOMEN
 Color Inspection Skin same color Skin same color Normal
with the rest of with the rest of
the body the body

 Symmetry of contour Inspection Symmetrical Symmetrical Normal

 Texture Inspection Smooth Smooth Normal

 Bowel sounds Auscultation Clicks or gurgling 21 per minute Normal

sounds occur
irregularly and
range from 5-35
per minute

UPPER EXTREMITIES
 Symmetry Inspection Symmetrical Symmetrical Normal

 Color Inspection Uniform with skin Uniform with Normal

color skin color

 Texture Palpation Smooth Smooth Normal

 Size Inspection Equal Equal Normal

 Range of motion Inspection Can raise both Can raise both Normal
arms without pain arms without
and discomfort pain and
discomfort
 LOWER EXTREMITIES
 Skin color Inspection Uniform with skin Uniform with skin Normal
color color

 Size (legs) Inspection Equal Equal Normal

 Symmetry Inspection Symmetrical Symmetrical Normal

 Swelling, lesions Palpation No edema and No edema and Normal

lesions lesions

HEART
 Heart sound Auscultation No murmurs or any No murmurs or any Normal
abnormal sound abnormal sound
 NEUROLOGIC
Level of Consciousness Interview Fully Fully Normal
conscious, conscious,
respond to respond to
questions questions
quickly, quickly,
perceptive of perceptive
events of events
Behavior and Interview Makes eye Makes eye Normal
appearance contact with contact with
the examiner, the
hyperactive examiner,
expresses hyperactive
feelings which expresses
response to feelings
the situation which
response to
the situation
MANNERISM, ACTIONS AND LANGUAGE
Voice inflection Interview Clear and Clear and Normal
strong strong
Tone Interview Fluent and Fluent and Normal
articulated articulated
Manner and speech Interview Can give Can give Normal
appropriate appropriate
answers to answers to
questions questions
MENTAL STATUS
Orientation Interview Oriented with Oriented Normal
three (3) with three
spatial aspects (3) spatial
aspects
TIME
Recall recent and remote Interview Recall events Recall Normal
memory readily, events
immediately readily,
recalls remote immediately
information recalls
remote
information
Judgment and thought Interview Can make Can make Normal
logical logical
decisions decisions