PHYSICAL ASSESSMENT (ADULT)
Name: Lepasana, Pedro Jr. Gender: Male
Age: 49 years old Date Examined: October 3, 2024
General Appearance:
Vital Signs:
T: 36.6 PR: 90 bpm RR: 19 cpm BP: 150/90 mmHg
ASSESSMENT NORMAL FINDINGS FINDINGS
INTERPRETATION
SKIN, HAIR, AND NAILS
Assess for skin Skin color ranges from
color, odor, and pale white with pink,
lesions yellow, brown, or olive Skin is dark brown in
tones to dark brown or color; no strong odor
black. No strong odor noticed; Normal
should be evident, and
the skin should be
lesions free
Skin should be soft, This indicates fluid
warm, slightly moist
with good turgor and retention due to
without edema or
lesions impaired kidney
Edema in the
extremities function that leads to
decreased ability to
excrete fluids.
Inspect and Hair is normally
palpate hair lustrous, silky, strong Hair is strong and
and elastic. Fine, downy elastic; Clean and dry; Normal
hair covers the body. Smooth and firm.
Scalp is clean and dry.
Hair is smooth and firm.
Inspect and Nails are cleaned. Pink This indicates
palpate nails tones should be seen. Capillary refill of more
Capillary refill of <2 than 2 secs. reduced blood flow
secs.
to the extremities,
often due to
cardiovascular
issues or fluid
imbalance.
HEAD, NECK, AND CERVICAL LYMPH NODES
Inspect and palpate Head size and shape vary. Symmetric, round,
the head Usually the head is
symmetric, round, erect, erect and in midline.
and in midline.
Hard, smooth, without
The head is normally hard
and smooth without lesions, Normal
lesions.
Symmetric; No
The face is symmetric with
a round, oval, elongated or abnormal movements
square appearance. No
abnormal movements noted.
noted.
Inspect and palpate Neck is symmetric with Symmetric without
the neck head centered without
bulging masses. bulging masses.
Neck movement should be Neck movement is Normal
smooth.
normal.
EYES
Inspect the sclera Sclera and conjunctiva are Clear, free of
and conjunctiva for clear and free of
color, discharges, discharge, lesions, discharge, lesions, Normal
lesions, redness, redness, or lacerations
and lacerations redness, or lacerations.
Observe the iris, No clouding of the cornea. No clouding of the
cornea and pupils Pupils are equal, round,
and reactive to light and cornea. Pupils are Normal
accommodation (PERRLA)
equal, round, and
reactive to light and
accommodation.
Finally inspect the Eyebrows should be Symmetric in shape
eyebrows and symmetric in shape and
eyelashes movement. They should and movement. Normal
not meet midline.
EARS
Inspect external No unusual structure or No unusual structure Normal
ears markings should appear on
the pinna noted.
Inspect internal No excessive cerumen, No discharge and
ears discharge, lesions,
excoriations, or foreign lesions noticed. Normal
body in external canal.
MOUTH, THROAT AND NOSE
Inspect Mouth and Mouth and throat is moist Moist; no mouth sore Normal
Throat and pinkish. No mouth
sore is noted. noted.
Observe the Gums appear pink and Gums appeared Normal
condition of the moist with tight margins to
lips, gums and the tooth. 28 teeth. Lips normal; complete teeth;
teeth are pink.
lips in normal color.
Inspect nose Nose is midline in face, In midline, straight ,
septum is straight and
nares are patent. and nares are patents.
No discharge or No discharge or Normal
tenderness is present
tenderness is present.
No flaring of the nose
Normal in color.
Color is the same with the
rest of the face
THORAX
Observe The client does not use This indicates
respiratory efforts accessory muscle
(trapezius and shoulders) that decreased
muscles to breathing. The
diaphragm is the major Decreased respiratory breath sounds
muscle at work.
Normal rate.
can indicate
respiratory rate:
12-20 per minute
effusion or
severe
consolidation.
Palpate for Client reports no Tenderness noted. This indicated
tenderness and tenderness, pain or
sensation unusual sensation tenderness
may suggest
liver
congestion or
because of his
condition .
Palpate surface Skin and subcutaneous Free of lesions and
characteristics tissue are free of lesions
and masses masses. Normal
Auscultate for No adventitious breath Crackles heard upon This indicates
breath sounds and sound heard
adventitious inhalation; wheezing is that crackles
sounds
present. suggest fluid in
the alveoli
(pulmonary
congestion),
while wheezing
may indicate
bronchospasm.
HEART
Auscultate for Normally no murmurs are No murmurs heard. Normal
murmurs heard
ABDOMEN
Inspect for Abdominal skin may be Pale in color Normal
coloration of skin paler than the general skin
tone
Inspect umbilicus Umbilicus is pink, no No discharge, odor,
discharge, odor, redness
or herniation. Umbilicus is redness noted. Normal
midline at lateral line
Percuss for tone Tympany predominates Asccites or fluid This indicates fluid
over the abdomen
accumulation in the overload.
abdominal cavity noted.
Palpate for masses Abdomen is soft to Tenderness on This indicates
and tenderness palpation and without
masses or tenderness palpation is noticed. liver or kidney
disease.
MUSCULOSKELETAL
Assess arms, Feet and legs are Symmetric and in size,
hands, feet and symmetric in size, shape
legs and movement. shape, and movement. Normal
Extremities should be
warm and mobile with
adequate capillary refill of
2 seconds
NERVOUS SYSTEM
Test CN I Client correctly identifies
(Olfactory) scent presented to each
nostril.
Test CN II (Optic) Client has 20/20 vision OD
(right eye) and OS (left
eye). Client reads print at
14 inches w/o difficulty.
Test CN III Eyelid covers about 2 mm
(Oculomotor), IV of the iris. Eyes move in a
(Trochlear), and VI smooth, coordinated
(Abducens) motion in all directions (the
six cardinal fields).
Bilateral illuminated pupils
constrict simultaneously.
Pupil opposite the one
illuminated constricts
simultaneously.
Test CN V Temporal and masseter
(Trigeminal) muscles contract
bilaterally. The client
identifies sharp and dull
stimuli and light touch to
forehead, cheeks and chin.
