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
