I.

PHYSICAL ASSESSMENT

BODY PART
General

CLINICAL FINDINGS
Awake, conscious, conversant, coherent and responsive

SIGNIFICANCE
Normal

Skin

Fair complexion Dry to touch Skin surface in non-tender No abrasion, lesion

Normal Normal Normal Normal

Head

Symmetric normocephalic Full of range motion (-) dizziness and headache Black in color Equally distributed Outer cantus align with tip of pinnas No swelling and discharge Sclera and conjunctiva are clear External ear no unusual structure (-) discharges Nose midline in face, no tenderness (-) mouth sores (-) bad breath Throat, tonsils easily seen Thyroid is palpable Trachea is centrally aligned Lymph node usually non palpable Breath sound may seem louder Respiration of 20 cpm (-) wheezes (-) cough

Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

Hair

Eyes

Ears

Nose and sinuses

Mouth

Neck

Chest

Breast Heart

symmetric cardiac rate of 80 bpm (-) tachycardia/bradycardia noted

Normal Normal

 Normal Upper extremities Arm: equal in size Dry to touch Have normal sensation Normal peripheral pulses Normal capillary time Normal Normal Normal Normal Normal

Lower extremities

With skin traction

Abnormal, Due to present condition