PHYSICAL EXAMINATION

I. General Appearance

Area Assessed Technique Actual Normal Analysis

Used Findings Findings
Body built Inspection Proportional Proportional Normal

Posture and Inspection Coordinated Coordinated Normal

gait and erect and erect

Body odor Inspection No body odor No body odor Normal

Signs of Inspection No distress No distress Normal

distress

Effect on Inspection Understandable Understandable Normal

mood

Speech Inspection Coherent Coherent Normal

II. Vital Signs

Area Assessed Technique Used Actual Normal Analysis

Findings Findings
Temperature Measured using a 36.6 degree 36.5 – 37.5 Normal
thermometer Celsius degree
Site: Axillary Celsius
09/23/2019
12:00 pm
Blood Measured using a 100/70 mmHg 90/60 - Normal
Pressure BP cuff and 120/80
sphygmomanometer 09/23/2019 mmHg
over brachial artery 12:04 pm
 Pulse Rate Measured the pulse 71 bpm 60 – 100 bpm Normal
over the radial
artery 09/23/2019
12:00 pm
Respiratory Measured by 17 bpm 12-20 bpm Normal
Rate counting the
number of breaths 09/23/2019
for a minute by 12:00 pm
counting how many
times the chest
rises.

Pain Scale Numerical Pain 0 0-10 (0 is the Due to

Scale lowest and 10 epidural
09/23/2019 is the highest) anaesthesia
12:00 pm
Oxygen Pulse oximeter 97 95-100% Normal
saturation
09/23/2019
12:00 pm

III. Skin

Area Assessed Technique Actual Normal Analysis

Used Findings Findings
Color Inspection Pail Light brown to Normal
brown
(Filipino)
Symmetry of Inspection Symmetrical Symmetrical Normal
the color

Edema Inspection Absent Absent Normal

Skin lesion Inspection Presence of No lesions Due to median

vaginal incision episiotomy

Moisture Inspection Moist Moist Normal

Temperature Palpation Warm to touch Warm to touch Normal

 Skin turgor Palpation Good skin Good skin Normal
turgor turgor

IV. Nails

Area Assessed Technique Actual Normal Analysis

Used Findings Findings
Nail curvature Inspection Convex 160o Convex 160o Normal

Texture Palpation Firm Firm Normal

Nail bed color Inspection Pinkish Pinkish Normal

Surrounding Inspection Intact Intact Normal

tissue

Capillary Palpation 2-3 seconds 2-3 seconds Normal

Refill

V. Head

Area Assessed Technique Used Actual Normal Analysis

Findings Findings
Hair distribution Inspection Evenly Evenly Normal
distributed distributed

Hair thickness Inspection Thick Thick or thin Normal

Texture & oiliness Inspection/palpation Oily Silky Normal

Infestation Inspection None None Normal

Body hair Inspection None None Normal

 Size and shape Inspection Normal Normal Normal

Contour Inspection Smooth Smooth Normal

Facial features Inspection Symmetrical Symmetrical Normal

Edema/hollowness Inspection/ None No edema Normal

palpation

Facial movement Inspection Symmetrical Symmetrical Normal

VI. Eyes

Area Assessed Technique Actual Normal Analysis

Used Findings Findings
Eyebrows Inspection Evenly Evenly Normal
distributed distributed
Eyelashes Inspection Evenly Evenly Normal
distributed distributed
Eyelids Inspection Intact skin, Intact skin, Normal
bilateral bilateral
blinking blinking
Conjunctiva Inspection Pinkish Pinkish Normal

Lacrimal Palpation No tenderness No tenderness Normal

gland
Cornea Inspection Clear Clear Normal

Pupils Inspection Black, equal in Black, equal in Normal

size, pupils are size, pupils are
equally round equally round
and reactive to and reactive to
light and light and
accommodation. accommodation.
(PERRLA) (PERRLA)
 Extra ocular Inspection Coordinated Coordinated Normal
movements
Visual activity Inspection Able to read a Able to read a Normal
book, not book, not
wearing wearing
eyeglasses eyeglasses

VII. Ears

Area Assessed Technique Actual Normal Analysis

Used Findings Findings
Pinna Inspection Uniform color Uniform color Normal
with skin, and with skin, and
symmetrical symmetrical

Ear canal Inspection Absence of Absence of Normal

cerumen/earwax cerumen/earwax

Hearing Inspection Responds when Responds when Normal

acuity called called

VIII. Nose

Area Assessed Technique Actual Normal Analysis

Used Findings Findings
Septum Inspection In midline In midline Normal

Placement of Inspection Symmetrical Symmetrical Normal

the nose and in midline and in midline

IX. Pharynx
Area Assessed Technique Actual Normal Analysis
Used Findings Findings
Uvula Inspection In midline In midline Normal

Oropharynx Inspection Pinkish Pinkish Normal

 Gag reflex w/ the use of Intact Intact Normal
tongue
depressor

X. Mouth

Area Assessed Technique Actual Normal Analysis

Used Findings Findings
Lips Inspection Symmetrical Symmetrical Normal

Teeth Inspection 20 pearly 20 pearly Normal

normal teeth normal teeth

Gums Inspection Pink, moist, Pink, moist, Normal

firm, and intact firm, and intact

Tongue Inspection In midline, In midline, Normal

pinkish and pinkish and
movable movable
Palate Inspection Light pink, Light pink, Normal
intact intact

XI. Neck

Area Assessed Technique Actual Normal Analysis

Used Findings Findings
Muscle Palpation Symmetrical Symmetrical Normal

Movement Inspection Coordinated Coordinated Normal

Range of Inspection Full Full Normal

motion

Muscles Inspection Equal Equal Normal

Strength

Lymph Nodes Palpation Not palpable Not palpable Normal

 Trachea Inspection In midline In midline Normal

XII. Chest and Lungs

Area Assessed Technique Actual Normal Analysis

Used Findings Findings
Breathing Inspection Regular Regular Normal
Pattern

Symmetry Inspection Symmetrical Symmetrical Normal

Spinal Inspection and Aligned in the Aligned in the Normal

Alignment palpation midline midline

Skin Inspection Smooth, no Smooth, no Normal

tenderness and tenderness and
lesions lesions
Breath Sounds Auscultation Clear Clear Normal

XIII. Heart

Area Assessed Technique Actual Normal Analysis

Used Findings Findings
Heart Sound Auscultation S1 louder at S1 louder at Normal
apex, S2 ape x, S2
louder at base louder at base

XIV. Abdomen
Area Assessed Technique Actual Normal Analysis
Used Findings Findings
Skin integrity Inspection Skin color is Skin color is Normal
uniform, no uniform, no
lesions lesions
Contour Inspection Flat Flat or rounded Normal
 Symmetry Inspection Symmetrical Symmetrical Normal

Bowel sound Auscultation High pitched High pitched, Normal

irregular
gurgles,5-35
times/min in all
quadrants
Percussion Percussion Generalized Generalized Normal
tympanic sound tympanic sound
Palpation Palpation No tenderness No tenderness Normal

XV. Back and extremities

Area Assessed Technique Actual Normal Analysis

Used Findings Findings
Muscle size Inspection Equal Equal Normal

Muscle tone Palpation Firm Firm Normal

Muscle No opportunity
strength

Bones Palpation No deformities No deformities Normal

Joints Palpation No tenderness No tenderness Normal

Range of No opportunity
motion