COMPREHENSIVE PHYSICAL EXAMINATION

General Survey: Patient was sitting on bed, conscious and coherent, oriented to place, person and time
with IV contraption of PNSS 1L on the right metacarpal vein running 60 cc/hr. Patient is cooperative and
uses simple words when communicating. Patient has medium frame body built with upright posture and
smooth rhythmic gait. No odor or obvious physical deformity noted.

Vital Signs:
o Temperature = 36.1C (axilla)
o Pulse Rate = 61 beats/min
o Blood Pressure = 130/80 mmHg
o Respiratory Rate= 15 breaths/min

Skin: Patient skin is of normal skin color, smooth and warm to touch, and elastic and mobile skin turgor.
No lesions noted. Hair is fine, thin and evenly distributed. Pallor on nail beds noted, nail plate is convex in
shape.

Head: Hair is short and black, with some graying. It is thick, fine and evenly distributed. No lesions or
infestations noted. Scalp is intact without lesions, lumps, or other masses. Head is proportionate to body
size and symmetrical in shape. No deformities, depressions, lumps, or tenderness. No discomfort upon
movement. Facial features are symmetrical, as well as facial movement.

Eyes: Both eyes are straight normal and parallel with each other. Eyebrows are thin and capable of
movement. No swelling, lumps or discharges noted. Effective closure of palpebral fissure and has a
bilateral blinking response. Eyeballs are symmetrical. Conjunctiva is pale. Sclera is white. Pupils are
reactive to light and accommodation. Patient can recognize object 12-14 inches away.

Ears: Auricles are symmetrical, normal in shape, and are of the same level. External canal is clear, with no
redness, swelling, lesions or discharges noted. Pinna recoils when folded with no tenderness. Responds
to normal voice 2 inches away.

Nose & Sinuses: External nose is normal in shape, position, and size. No bleeding, swelling, lesions, or
masses noted. Nasal Septum is at midline and without perforations, lesions, swelling, or bleeding. Mucosa
is pale upon inspection. Both patent and nasal cavity is dry. No tenderness upon palpation of the Frontal
and Maxillary Sinuses.

Mouth & Oropharynx: Lips appeared pale and dry. No halitosis noted. Oral mucosa is moist, smooth, and
free from lesions. Tongue is at midline, movable and pink in color with rough texture. Teeth are
incomplete and carries were noted. Patient does not use dentures. Pallor was noted on gums.

Neck: Neck muscles are equal in size with full ROM. No distension of jugular vein noted. No enlargements,
palpable masses, and tenderness noted. No enlargement of thyroid gland noted. No tracheal deviations.
Carotid pulse is palpable.

Breast: Breasts are bilateral, and symmetrical in shape and size. No lesions, masses, dimpling, or
tenderness. Nipples are symmetrical in shape and size. They are dark brown in color. No discharges,
rashes, and ulceration noted.
Thorax & Lungs: shape of chest is normal with symmetrical lung expansion. Tactile fremitus is
symmetrically heard. Breathing pattern is regular and normal lung sounds were heard upon auscultation.

Upper Extremities: The patient’s arms are thin, smooth, and are warm to touch. Muscles, bones, and
joints are symmetrical without swelling, deformities, fasciculation, or abnormal positioning. Patient has a
full range of motion with good muscle strength and tone. Peripheral pulses are palpable and normal.

Lower Extremities: Able to move and raise feet and legs with no discomfort. No varicose veins present.
No swellings, masses and deformities not on both legs. Muscles, bones and joints are symmetrical. Patient
has good muscle tone and strength. Can raise legs against resistance. Peripheral pulses are palpable and
normal.

Genitourinary/Genitoanal Area: Not performed.