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Physical Assessment Format

Physical Assessment Format

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Published by anreilegarde

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Published by: anreilegarde on Mar 02, 2011
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07/06/2013

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BODY PARTTechniqueusedNORMAL FINDINGSACTUAL FINDINGSANALYSIS
SkinInspectionUniform in color; noabrasions or any lesionsWell moistened skin.
HEAD
SKULL &FACEInspectionPalpationRound or normocephalic;smooth, absence of nodules or masses;symmetric facialmovements.HAIRInspectionEven distribution of hair,resilient thick hair withno signs of infections or infestations.EyebrowEyesEyelashesEyelidsPupils (color ,shape andsymmetry of size)InspectionInspectionInspectionInspectionInspectionEvenly distributed hair;eyebrows symmetricallyaligned;Lids close symmetrically;shiny smooth, pinkishconjunctiva; no edema or tenderness.Equally distributed,Curled slightly outwardSkin intact, No discharge, Nodiscoloration,Lids close symmetricallyBlack in color, equal insize normally 3-7 mm indiameter,round smooth border , irisflat and round.EARInspectioncolor same as facial skinsymmetrical; mobile,firm and not tender; No notable discharges
 
normal voice tonesaudible NOSE ANDSINUSESInspectionSymmetric and straight;no discharge or flaring;not tender, no lesions.Uniform in color Air moves freely as the patient breaths throughthe nares. No tenderness inmaxillary and frontalsinusesMOUTHTONGUETEETHInspectionInspectionInspectionUniform in pink color;symmetrical lips.in central position; pink in color moves freely with notendernessSmooth tongue base with prominent veinsSmooth with no palpablenodulesUvula positioned inmidline of soft palate.gag reflex present32 adult teeth, smooth,white,
 
shiny tooth enamelno retraction of gums
 
 NECK MUSCLESLymph nodesInspectionPalpationPalpationCoordinated, smoothmovement with nodiscomfort. Has equalmuscle strength. Not palpableUpper extremitiesInspectionPalpationMuscle:Equal size on both sidesof the body No contracturesBones: No skeletal deformities.Joints: No swelling, tenderness,crepitation or nodules.Moves freelyThorax andLungsInspectionAuscultationPalpationPosterior thorax:Symmetry:Spine vertically aligned;spinal column is straight,right and left shoulderships are the same inheight.Skin intact; uniformtemperature No tenderness and no presence of massesVesicular and broncho-Vesicular breath soundsAnterior thorax:Quite, rhythmic, andeffortless respirations No tenderness and no presence of massesAbdomenInspectionAuscultationPalpationUnblemished skinUniform in color Flat, rounded or scaphoidSymmetric movementcaused by respirationAudible bowel soundGENITALS

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