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 INTERPRE
USED FINDINGS TA-TION

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

Color Uniformity Inspection Generally uniform except Generally uniform Normal

in areas exposed to sun

Edema Inspection No edema No edema noted Normal

Palpation

Temperature Palpation Normally warm to touch 36.1C Normal

Texture Palpation Smooth, soft and flexible Smooth, soft, and Normal
Inspection palms and soles (thicker) flexible palms and
soles (thicker)

Turgor Palpation Springs back to previous Springs back to Normal

state previous state
(1-2 seconds) (1-2 seconds)

Moisture Inspection Skin Normally Dry Skin normally dry Normal

Palpation

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 2-
(Blanch Test) return within 2-3 seconds 3 seconds

Tissue surrounding Inspection Intact epidermis Intact epidermis Normal

nails
 HAIR
Color Inspection Varies from races, usually Black Normal
black among Filipinos

Thick hair strands

Hair Strands Inspection Thick hair strands Normal
Evenly distributed
Distribution Inspection Evenly distributed Normal
Smooth
Texture Inspection/ 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 lesionsNo tenderness and Normal

displacements of lesions
bones and cartilage
Evenly distributed
Cilia, hair Inspection Evenly distributed Normal
Oval, symmetric and
Nares Inspection without discharge Oval, symmetric and Normal
without discharge
 MOUTH AND PHARYNX
Due to
Lips Inspection Pinkish, moist, Pale, dry, symmetrical Not normal mild
symmetrical dehydratio
Glistening pink, n
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 Normal
color skin 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 No murmurs or Normal
any abnormal any abnormal
sound 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