PHYSICAL ASSESSMENT

PATIENT: N

AGE: 21 YEARS OLD

Date of Physical Assessment: Feb 14, 2019

Materials used:
-physical assessment tool -penlight -tape measure
-pencil -tongue depressor -watch with secondhand
-gloves -BP apparatus with stethoscope -mask -
weighing scale -mild scented cologne

Legend: Red font - Abnomal Black font -Normal

INITIAL ASSESSMENT
VITAL SIGNS ACTUAL OBSERVATION
Temperature 36.6⁰C
Pulse Rate 60 bpm
Respiratory Rate 20 bpm;
Blood Pressure 120/80 mmHg

STATISTICS ACTUAL OBSERVATION

Head Circumference 50 cm
Chest Circumference 80 cm
Abdominal Circumference 77 cm
Weight 730 kg
Height 5’11
Computed BMI 22.4

GENERAL SURVEY ACTUAL OBSERVATION

Body Build Body is proportionate and has a slight curvature at the back
Posture Body is relaxed and coordinated
Hygiene and Grooming Long dirty nails
Attitude -cooperative but cannot concentrate and easily distracted

Affect/Mood Anxious

ASSESSMENT INSPECTION PALPATION PERCUSSION AUSCULTATION

Skin -skin color is -dry
“brown” -distended veins
-with vellus hair feet and hands
present -skin turgor returns
-Skin cuntosion at left within 3 second
peri orbital area
-abrasion right
shoulder
Hair -hair is thin -hair is smooth and
-well distributed oily
Head -Round in shape -no nodules upon
-has symmetric palpation
features and
Movement
Eyes

 Eyebrows - hair on the

eyebrows are evenly
distributed,
symmetrically
aligned, and has equal
movement

 Eyelashes -slightly droop

-eyelids has an intact

skin, there were no
 Eyelids discharges noted,
closes symmetrically,
and upper and lower -no tenderness noted
boarders of the
cornea slightly
covered when lid
opens

-pink in color
 Bulbar
conjunctiva

-shiny and is pink and

 Palpebral has some capillaries
conjunctiva seen

-no edema and pain

 Lacrimal gland noted

--white in color, shiny

and some capillaries
are visible
 Cornea
-black in color, equal
in size round in
shape, and Both
 Pupils
pupils constrict to
light.

- parallel alignment;
moves in unison
 Extra-ocular
muscle
Can read slowly and
count fingers 1 feet
away
 Visual Acuity
Ears
 Auricles
 -color is the same of -pinna recoils
the facial skin and immediately, firm
symmetrical and mobile
 Ear Canal
-with a little hair
follicles visible and
with yellowish
cerumen present
 Gross Hearing
-have no difficulty
hearing
Nose and Sinuses
 Nose -symmetric -there were no
externally, , tenderness or
lesions,uniform in deviation of
color, air moves cartilages noted and
freely as patient nasal septum is in
breaths, can smell the midline and is
mild scented cologne intact and not
100m away and perforated
mucosa is pale in
color
 Sinuses -facial sinuses not
tender and no pain
reported
Mouth and
Oropharynx
 Mouth -there are some
 Teeth cavities on all of the
teeth, first and second
molar of upper right
side are decayed, all
teeth are yellowish in
color.

 Lips and Buccal -lips are pink in color, -lips is smooth, and
Mucosa moist, soft, there were no
symmetric and is able nodules or lesion
to purse lips found upon
palpation

 Tongue -pale in color, found

on the center and
moves freely

 Palates/Uvula - pale in color,

smooth, and is found
at the midline

 Oropharynx -pale in color and -smooth in texture

with positive
presence of gag reflex
Neck
  Neck muscles -muscle equal in size,
movements are
coordinated and has
equal strength
-not visible

 Lymph nodes -no enlargement -no palpable and

tenderness of lymph
nodes

 Trachea -placement is in the

center

 Thyroid Gland - not visible during -no tenderness is

inspection, no present
swelling gland
ascends when
swallowing
Thorax and Lungs -chest expansion is -no tenderness and -lungs resonates - no adventitious
symmetric masses noted upon percussion sounds
-rythmic

Heart and Central -jugular vein not -correct pulsations at -full pulsations -no bruit sounds upon
Vessels visible correct place auscultation
-no pulsations in the
pericardium seen
Breast and Axillae -generally rounded -no nodules, masses,
and symmetric tenderness, and
-intact nodules noted
-everted nipples -smooth in texture
-no discharges
Upper Extremities -joints moves - strong pulse noted
smoothly and noedema noted
-nails are convex at - capillary refill time
160⁰ angle 3 seconds (delayed)
-nails are smooth to
touch
-intact epidermis
-Paresthesia on right
arm arm.
-bandage splint at
right arm
Gastric -Normal gastric -with 20 clicks/minute
emptying; defecates
1x/day
stool yellowish in
color.

Lower Extremities -joints moves freely -no tenderness and

-nails are convex at edema noted
160⁰ angle - capillary refill time
-no presence of 3 seconds (delayed)
distended veins -nails are smooth to
-equal in size touch
-no tremors -weak pulse on
-no bone deformities dorsalis pedis,
 -joints move freely posterior tibial,
-intact epidermis popliteal.
-distended veins

ASSESSMENT INSPECTION AUSCULTATION PERCUSSION PALPATION

Abdomen -slightly rounded, -presence of bowel -not dull -normal bowel sounds
symmetric movements sounds (20clicks)
No pain no ted