PHYSICAL ASSESSMENT

Date & Time: July 8, 2013 11:20 A.M

General Appearance:
The patient is male with IVF of # 2 PLR 1L x 30 gtts/min at the level of 500cc, hooked at left
cephalic vein, patent infusing well. Hair is not fixed well, tinea flavae can be seen in his
forehead. He is conscious and well oriented by the time, place and people around him. He speaks
well with clear and audible voice.
Vital signs:

BP: 100/80 mmHg

Temp: 37.2 C

PR: 84 bpm

RR: 20cpm

Head/Hair/Scalp:

Inspection: Head is proportional to the body and skull is rounded and

symmetrical, no dandruff and lice noted, hair is evenly distributed, black in color with dry
texture.

Palpation: No tenderness and masses noted.

Face:

Inspection: The face is symmetrical, skin is brown in complexion. Presence of

tinea flavae noted on the forehead. No scars noted.

Palpation: There is no masses and tenderness noted, warm to touch.

Eyes:

Inspection: The eye is symmetrical, and eyebrow is black in color and its evenly
distributed, eyelid are able to close completely. Eyelashes directed outward and intact.
Pupils are equals in size, round in shape and reacts to light and accommodation.
Conjunctiva is pale in color, sclera is well lubricated, light yellowish in color, the cornea
is clear and transparent, and iris is black in color. Periorbital noted.

Nose:

Inspection: The external nose is symmetrical, align at the midline, mucosa is

moist, nasal septum is intact, no lesions and nose deformities noted.

Palpation: There is no tenderness noted.

Ears:

Inspection: Ears are symmetrical, normal in size with equal color to the body
complexion, no lesions noted, small amount of dirt accumulates at the external ear,
earwax noted, auricle has no deformities, pinna recoils when folded.

Palpation: No tenderness and lymph nodes noted.

Lips and Mouth:

Inspection: Lips is red in color with dry and flaky texture, no presence of
stomatitis, no lesions noted, the tongue is pinkish in color. No dentures noted with
incomplete set of teeth. Gums and mucosa is pink and no lesion noted. Tonsils are not
inflamed; uvula is bell in shape, pinkish in color, and at the midline.

Neck:

Inspection: Jugular veins are not inflamed and no stiffness noted.

Palpation: Lymph nodes at the neck are not palpable.

Breast:

Inspection: Brown areola and nipple noted, areola are equal in size.

Lungs:

Auscultation: Breathing pattern is normal and no irregular rhythm noted. No

crackles noted.

Heart:

Auscultation: No abnormal sound noted.

Abdomen:
Inspection: No scars noted upon inspection. No lesion.
Auscultation: Gurgling sound noted 12 beats/min.
Palpation: Tenderness noted, no masses noted. Pain is felt when palpated.

Extremities:

Inspection: Extremities are proportionate to the trunk; skin is brown in

complexion, symmetrical on both upper and lower extremities, no difficulty in
performing flexion and extension. Muscle is equal strength, and can do fine motor
movements.

Skin:

Inspection: Fair complexion, lesion noted and hair is evenly distributed. Skin has
good skin turgor.

Palpation: No masses and tenderness noted. Cool to touch.

Nails:

Inspection: Nails are pinkish in color, trimmed and no presence of dirt under
nails, delayed capillary refill.

Date and time: July 8, 2013 1:00 PM

REVIEW OF SYSTEMS
General Survey:
Patients claims: sa nanligad nga anom ka bulan, medyo mayo man ang
nabatyagan ko halin sa paghalin ko diri hospital, nag ayo gid ang pamatyag ko kay diri ako ulihi
gin admit sadto. Wala man ako gin ubo, gin sip-on, trangkaso o kung gin atake sang kung ano
nga sakit, gaskit lang gid pirme ang tiyan ko.

Skin/Hair/Nails:
Patient claims: Wala man ako sang mga katol-katol sa akon nga panit. Pero may alap-ap
ko sa akon agtang banda. Kita mo?
Head:
Patient verbalized: May nabatyagan ko nga lingin sang ulo ko kung inang gulpi ako
magtindog, kag galingin akon ulo.
Eyes:
Patient Patient verbalized: Kung lapit, hindi ako kakita, pero kung layo makakita ako.
Ears:
Patient verbalized Wala man sang deperensya ang akon talinga. as verbalized by the
patient .
Nose:
Patient verbalized: Wala man ko problema sa akon pang amoy kag wala man gasakit
akon ilong.
Lips:
Patient claims: Wala man problema sa akon bibig, wala man singaw o kun pilas as
verbalized by the patient.
Mouth and throat:
Patient claims: Wala man problema sa akon baba pero kis-a gakatol akon tutunlan.

Neck:
Patient verbalized: Wala man gasakit liug ko.
Respiratory system:
Patient verbalized: Kis-a nabudlayan ako mag ginhawa, nang daw gagutok akon pag
ginhawa.
Cardiovascular system:
Patient verbalized: Way man ga sakit akon nga dughan, wala man ko kaagi opera sa
puso.
Musculoskeletal:
Patient claims: Kis-a gasakit akon mga buko-buko ang akon mga tuhod. May
rheumatoid arthritis abi ako. as verbalized by the patient.
Gastrointestinal system:
Patient verbalized: Gasakit ang akon sulok-sulok kag ang tiyan ko daw puno kis-a sang
hangin. Sakit akon tiyan pirmi nga kung kis-a gakonekta siya sa likod ko.
Breast:
Patient verbalized: Wala man sakit sa akon nga titi.
Genitourinary:
Patient verbalized: Wala man ko ga ihi-ihi pirme. Wala man problema sa akon pag ihi
Hematology:
Patient claims: Wala man kuno problema sa akon dugo. as verbalized by the patient.
Psychiatric:
Patient verbalized : Wala man ko problema sa akon pa-isip. Pero kis-a damo lang gid ko
nga gina isip nga mga problema namon.