ADAMSON UNIVERSITY

College of nursing
PHYSICAL ASSESSMENT

Name of the client:__________________________Age:________Sex:_______

FINDINGS
AREA/SYSTEM
Vital signs:
General Survey

Skin and nails

head

EENT:

Neck

Thorax and
lungs

Well groomed, no anybody fat is distributed properly.

Facial expression appropriate to speech.
Inspection: skin is brown in color and uniform throughout
the body.
Palpate: skin is smooth and moist.
Inspect for nails: nails are clean and pinkish.
Inspection: hair is well distributed although some is white.
Symmetric facial features.
Palpate: no masses, nodules or any swelling.
Inspect for the eyes: constricts as lighted (pupil reflex).no
swelling. Bulbar conjunctiva is clear, and moist.
Inspect for the ears: appropriate amount of cerumen,
Palpate: no nodules or masses and any tenderness.
Inspect for the nose: color is the same as the rest of the
face.
Inspect the throat: tonsils are red, and enlarged.
Inspect: with tenderness at the left side of the neck
because of tonsillitis

Posterior thorax
Inspection:scapula are symmetric
Palpation: the client is with tenderness
Assess chest expansion: the client deep breath will move
5 to 10 cm apart symmetrically.
Auscultate: no any crackles or any extra unnecessary
sound is heard.

Anterior thorax:
Inspect: sternum is position at the midline and straight.no
bulging of intercostal spaces.
Palpate: no masses and nodules.
Percuss for tone: elicits dullness over breast tissue
inspect:
Breast:

Heart and
peripheral
vasculature

Inspect: symmetry, texture is smooth with no edema.

Palpation.no masses will palpate.
Inspect for the heart: the apical impulses not be visible.
Palpate: no pulsations are palpated in the area of the
apex.
Auscultate: s1 and s2 is heard clearly.no any unnecessary
extra sound are heard.
Observations of arms are bilaterally symmetry with
minimal variation in size and shape.
Palpate for the capillary refill time, capillary beds refill in 2
seconds.
Allen test, pink coloration return to the palms within 3 to 5
seconds to the palms.no edema will palpate.

abdomen

No masses and lesions, bowel sound heard at the both

side.

Musculoskeletal
system

Proper movement, tendons are percussed and the

connection moves and react.no masses, nodules and
swelling in major ligament and tendon.
Proper gait. Walks straight.no difficulty in walking in heels,
toes and one leg proper equilibrium in performing
Romberg test.

Neurologic
system

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ASSESSED BY: