PHYSICAL ASSESSMENT

I. Personal Data

Name: Casitro Tabas

Age: 33y/o

Nationality: Filipino

Religion: Roman Catholic

II. Health History

a. Past Illness

According to the patient he did not have any illness before other than common flu
including headache, cough and colds.

b. Present Illness

According to the patient he had been hospitalized last year September 2009 of
the same diagnosis as of now but his first admission the physician thought it was
hepatitis but after the result of laboratory test, they found out that the real diagnosis is
obstructive jaundice secondary to choledocholelithiasis

III. General Survey

Casitro Tabas, 33 years of age, male. He was admitted on July 23 2010 at

Southern Philippines Medical Center. Prior to assessment, he was received awake,
responsive, and coherent with IVF of D5LR infusing well on right metacarpal vein at rate
of 120 cc/hr at a level of 700ml.

`Vital Signs

BP: 120/80 mmHg T: 36.5°C

PR: 80 bpm RR: 14 cpm

IV. Skin
 Skin is dark complexion and there is absence of lesions. Scar noted on the right
foot. Skin is warm and dry upon palpation. Skin turgor is poor as the skin returned to its
previous state 3 seconds after being pinched.

V. Head

Patient’s head is round and symmetrical in appearance. No abnormal growth

noted. Hair is black, short and evenly distributed through the scalp. Scalp is oily and with
no lesions. No parasites noted.

VI. Face
The shape of his face is round. With grimace faced noted, able to elevate and
lower eyebrows. Facial hair noted. No involuntary movements or mannerisms. No
masses and lesions noted.

VII. Eyes
He is without corrective lenses. Eyebrows symmetrically aligned at rest; exhibits
equal movement. Eyeballs were yellowish in color and aligned bilaterally. Lashes are
equally distributed and are slightly curled outward. Eyelids are closed symmetrically.
The patient has a normal pupillary reaction.

VIII. Nose
Patient’s nostrils are symmetrical. No swelling or obstruction noted. No
discharges noted and air exchange is free and without noise when inhaling.

IX. Ears
Ears are symmetrical in shape and size. No deformities noted. No
discharges noted and patient can hear well.

X. Mouth

Lips appeared dark in color and not moist, symmetrical at rest and when
moving. Gums are dark in color. Tongue is pinkish in color and moves freely. No
dentures seen on the teeth. Patient can differentiate kinds of tastes when tasting.
No difficulty in swallowing.

XI. Neck

Anterior and posterior part of the neck is symmetrical. No masses and

unusual swelling noted upon palpation. Patient’s neck has normal range of
motion. No discomfort noted.

XII. Chest

There is symmetrical chest wall expansion. No wheezing breath sounds

noted upon auscultation.

XIII. Abdomen

Abdomen is flat. Pain is present in the right upper quadrant. It has the
same color with the other parts of the body.

XIV. Genito-Urinary

No catheter noted. Patient’s urine is dark in color.

XV. Back and Extremities

Back part of patient is smooth and with no lesions noted. Skin color is
uniform with other parts of the body. Nail beds are dry, pale and trimmed with
capillary refill of 4 seconds. Both upper and lower extremities are hairy noted.
Lower extremities have scars noted.