IX.

COMPREHENSIVE PHYSICAL EXAMINATION

A. Vital Signs

Date / Time of Exam: 17 April 2019

T 36.5˚󠆸C

RR 17 cpm

PR 60 bpm

Bp 80/60 mmHg

Pain The client verbalized that she had an acute

abdominal pain on her umbilical and hyper

gastric area which she rated as 6/10 that

occurs when she turns in sudden,

stretching herself or when one palpates the

area of incision.

The client appeared slumped shoulders

neck forward guarding her abdominal area

with her hands.

Client’s facial expression indicated distress

,discomfort and grimacing

 Anthropometric Data

Height

Weight 17 kg

Abdominal circumference

IBW

General Appearance

The client appeared as the stated age. She is an ectomorph patient with limited ambulation due

to instilled IV fluids medications. The client appeared slumped shoulders neck forward guarding

her abdominal area with her hands.

Client’s facial expression indicated distress ,discomfort and grimacing .She had no unusual

body odor and She dressed in clothing of good condition appropriate for the climate. The client

did not maintain eye contact with the examiners ,but she responded appropriately and relevantly

to the asked questions. The client’s fingernails were however long averagely cleaned.

Date of P E April 17th 2019

Body Part Actual Findings Normal Findings Clinical

Examined Significanc
e

Skin Inspection of the client Inspection

revealed :
Normally inspection reveals:
● A uniform light
pink Skin color
without pallor,
 jaundice, or ● Skin colour with no
cyanosis areas of pallor,
● No foul odor jaundice, or cyanosis
● No bruising,
● Absence of erythema, or areas of
bruising, discoloration are
erythema, or areas apparent
of discoloration ● Skin texture looks
● Normal variations smooth and intact
in pigmentations ● Normal variations in
such as pigmentations such
birthmarks, as birthmarks,
freckles and nevi – freckles and nevi –
exist exist
● No swelling ● No presence of
● No presence of edema
lesions or any skin ● No presence of
abnormalities lesions or any skin
abnormalities

Palpation revealed Palpation

● A smooth, warm ● Skin feels smooth and

and intact to feel warm without thicken,
skin with absence or broken areas
● Skin is relatively dry,
of thickened, or
without excessive
broken areas. perspiration or red,
● A relatively dry flaky areas
skin, without ● Skin quickly returns to
excessive its original shape
perspiration or red, when gently pinched
flaky areas
● Skin quickly
returned to its
original shape
when gently
pinched

Hair Inspection revealed Inspection

Normally inspection
reveals:

 The hair should be

 Black thin hair
equally distributed
 Client had no
brittle hair
 No infection
detected during
equally distributed
 The hair should not
be brittle
 No infection should
be detected
 the Physical
assessment

Palpation Palpation

● Hair was smooth  Hair is smooth

to touch  No too much oil
● Hair was not oily
to touch

Nail Inspection revealed: Normally inspection Dirty and

reveals : long nails
● Dirty long is a sign of
finger nails ● Nail bed colour unmet
● Pink, Nail bed ranges from pink to
● Slightly curved hand
brown, depending on
finger nails skin colour hygiene
● No presence of ● Nail bed is slightly
paronychia curved or flat
infection ● No presence of
paronychia
Palpation Palpation

● Smooth to touch ● Capillary refill in less

● Color of the nail than 3 seconds
bed back to
original color in
less than three
seconds.

Skull and face Inspection Inspection

● Scull  Normocephalic
symmetrical  Symmetrical
●
Palpation Palpation

● The skull was ● There should be no

smooth visible masses,
● No masses, nodules or
depressions and ● smooth skull contour,
nodule palpated firm
● No depressions felt

Eyebrows Inspection Inspection

● Eyebrows black Hair is evenly

evenly distributed, distributed,
symmetrically symmetrically
aligned with equal aligned with equal
movement movement.
Eyelashes Inspection Inspection
 ● Eyelashes were  Equally distributed
black and Equally and curves outwards
distributed with
outward outwards
curves.
Eyelids Inspection revealed Inspection

● Eyelids was intact  Skin is intact when

when eyes are eyelids are closed.
closed.  Eyelids partially
● Eyelids partially covering the top part
covering the top of the pupil.
part of the pupil.  Blinks properly and
● Blinks properly eyes open and close
and eyes open together
and close together
Bulbar Inspection Inspection
conjunctiva
● Bulbar conjunctiva ● Bulbar conjunctiva is
And was clear, moist clear, moist and
and smooth. smooth. Underlying
Palpebral Underlying structures are clearly
conjunctiva structures were visible.
clearly visible. ● The lower and upper
● The lower and palpebral conjunctiva
upper palpebral are clear, absence of
conjunctiva are swelling or lesions
clear, absence of ● Palpebral conjunctiva
swelling or lesions has no swelling, no
● Palpebral foreign bodies or
conjunctiva has no trauma
swelling, no
foreign bodies or
trauma
Lacrimal Inspection Inspection
apparatus
 No edema or ● No edema or tearing
tearing of the of the lacrimal gland.
lacrimal gland.
Cornea Inspection Inspection

 Transparent, shiny ● Transparent, shiny

and smooth and smooth
 Lens was free of ● Lens is free of
opacities opacities
Pupils Inspection Inspection

•Pupils are black  Pupils are black

•Client had a 3  2 to 4 mm in size
mm of pupil in  Illuminated pupil
size constricts
•Illuminated pupil  Non-illuminated
constricted with pupil dilates
light
Visual acuity Inspection Inspection

● The client read the ● The client should be

words on the able to read the
paper that was words on the paper
held 12 inches that was held 12
away from her inches away from her.
Nose Inspection Inspection

 The client’s nose ● Nose is symmetrical

was symmetrical and lesion free, with
and lesions free, no deviation of the
with no deviation septum or discharge
of the septum or ● No nasal flaring is
discharge apparent
 No nasal flaring ● Nose is the same
was apparent colour as the skin
 The nose was of ● No visible discharge
the same color as should be seen
the skin, light pink
 No visible
discharge was
seen
Palpation Palpation

 There was no  No tenderness or

tenderness or masses upon
masses upon palpation
palpation
Inspection Inspection Angioede
Face Inspection revealed  Uniform skin without ma is an
swollen face lesions, area of
 No masses swelling of
 No birth marks the lower
 No swelling
layer of
skin and
tissue just
under the
skin or
mucous
membrane.
The
swelling
may occur
in the face,
tongue,
larynx,
abdomen,
or arms
and legs.

The
underlying
 mechanis
m typically
involves
histamine
or
bradykinin.
The
version
related to
histamine
is due to
an allergic
reaction to
agents
such as
insect
bites,
foods, or
medication
s.

Nasal mucosa Inspection revealed Inspection

 Nasal mucosa of  Nasal mucosa is

the client was pinkish red
pinkish red  No visible swelling or
 No visible growth within
swelling or growth  No visible discharge
within
 No visible
discharge
Lips Inspection revealed Inspection

● Lips were pinkish Lips should be

in color according
to her skin tone
● Client had pink lips
without lesions
and swellings
● Symmetrical lips
Teeth Inspection revealed Inspection
pinkish or pink in
colour or light brown
depending on skin
tone
 Lips are smooth and
moist without any
lesions or swelling
 Symmetrical
 Have slight vertical
linear markings

● Client had 26 teeth ● teeth in total

in total
● No cavities
● Yellowish in colour
● Appeared sharp
edged
● No dental fillings
● No cavities
● Yellowish or white in
colour
● Smooth edge
● No dental fillings
● No halitosis
 ● No halitosis
●
Gums Inspection Inspection

 No bleeding was ● There should not be

inspected any bleeding
 Pink gums colour ● The gums should be
 No any lesions or pink or pinkish in
swellings was colour
revealed. ● There should no any
lesions or swellings

Tongue Inspection Inspection

● Dorsal surface ● Dorsal surface should

was symmetrical symmetrical
● Midline groove ● Midline groove should
was visible be visible
● Small fissures ● Small fissures
inspected ● The ventral side
● The ventral side should be smooth
was smooth and ● Pink
Pink ● Visible veins
● Visible veins
inspected
Palates Inspection Inspection

● Hard palate was ● Hard palate should be

whitish and whitish grey or whitish
appeared bony and should appear
● The soft palate bony
was pink in color ● The soft palate is
muscular and pinkish
Uvula Inspection Inspection

● The uvula was ● The uvula should rise

risen with the soft with the soft palate
palate when when saying “ahh”
saying “ahh” and it and it should remain
remained at the at the middle
middle
Tonsils Inspection revealed Inspection

● The client had ● Pink and smooth

Pink tonsils ● There are no
without swellings abnormal discharges
● There were no ● The patient’s vagus
abnormal and glossopharyngeal
discharges nerves should work
● The client’s gag when tested with the
reflex was present. gag reflex
Palpation Palpation

 No nodules
 ● The client’s tonsils  No lumps
were smooth  No excoriated areas
without nodules
● No lumps
● No excoriated
areas

Neck muscles Inspection Inspection

● Absence of Absence of masses

masses and or any abnormal
abnormal swellings
swellings  Head should move
● Head moved smoothly
smoothly with  The muscle strength
equal strengths of on each shoulder
both shoulders. and on each cheek
should be equally
strong
Lymph nodes Palpation Palpation

● There were no ● Lymph nodes should

palpable have no enlargement
enlargements on upon palpating
the lymph nodes
Trachea Palpation Palpation

● The trachea was ● Trachea should be

symmetrical and symmetrical and
positioned at the should me positioned
middle at the middle
Thyroid gland Inspection Inspection

 The thyroid gland  Thyroid gland

was symmetrical should be
 It moved up and symmetrical
down when the  Should be visible
client asked to upon swallowing
swallows  No visible
 There were no enlargement or
enlargements or masses
masses visible
during
assessment
Palpation Palpation

 The thyroid gland  The thyroid gland

were smooth should be smooth
without without any
enlargements
enlargement when
palpated

Auscultation Auscultation
  No bruit sounds There should be no
were detected evidence of bruit sounds
during auscultation when auscultated

Posterior thorax Inspection Inspection

●Chest configuration was ● Chest configuration is

symmetrical side to side symmetrical side to
●Chest shape was normal side
without deformities upon ● Chest shape is
inspection. normal with no
deformities

Palpation Palpation

 Skin was warm  Skin is warm and

and dry to touch dry
with an auxiliary  No tender spots or
temperature bulges in chest are
detectable
36.2◦C
 There should not be
 No tender spots any strained
or bulges in chest movements when
are detectable breathing
 There no strained
movements when
breathing

Percussion Percussion

 Resonant sounds Resonant sounds

were heard over can be heard over
the lungs the lungs
Auscultation Auscultation

 loud, high -  loud, high - pitched

pitched bronchial bronchial breath
breath sounds sounds can be
were heard over heard over the
the trachea trachea
 Intense, medium -  Intense, medium -
pitched breath pitched breath
sounds were also sounds can be
heard over the heard over the
main stem mainstem bronchi,
bronchi, between between the
the scapulae and scapulae and below
below the the clavicles.
clavicles.  Soft, breezy, low -
 Soft, breezy, low - pitched vesicular
pitched vesicular breath sounds can
breath sounds
be heard over most
heard over most
 of the peripheral of the peripheral
lung fields. lung fields.

Anterior thorax Inspection Inspection

● Breathing pattern ● Breathing pattern

were smooth and should be smooth
irregular

Palpation Palpation

● There were equal ● The thumbs would

expansion of the separate with equal
lungs expansion
● Absence of
● tenderness and
masses
Auscultation Auscultation

 No abnormal  Absence of abnormal

breath sound and breath sound and
auscultated auscultated crackles
crackles
auscultated

Heart Auscultate Auscultate

 No presence of ● No presence of heart

heart murmur murmur
 No tachycardia ● No tachycardia
auscultated
Breast Breasts are flat ● Breasts colour are
and symmetric lighter than other
with pink areola parts of skin
 No masses ● No masses
 No nodules ● No nodules
Areola  Pink areola ● or light brown
● No dermatitis
● No masses
● No lesions
Nipples Inspection Inspection

 No inversion ● No inversion
 No retraction ● No retraction
 No deviation ● No deviation
 No discharge ● No discharge
  No rashes ● No rashes
 No ulcerations ● No ulcerations
Abdomen Inspection Normally Inspection
reveals:

 Abdomen of the  Skin color is uniform,

client appeared no lesions.
slightly prominent
when sited but  No venous
flattened in supine engorgement.
position The
 Contour may be flat,
 Client had a dry protuberant, rounded paramedic
paramedical or scaphoid al incision
incision with is an
sutures evidence
 No venous of the
engorgement.
incision
 Contour may be
flat that was
made on
the client’s
abdominal
region to
correct
intestinal
malfunctio
n

Auscultation Auscultation

 Not done Normal bowel sounds

occurs every 10 to 30
seconds , they are like
clicks, gurgles or grows.

MUSCULOSKE Inspection Inspection

LETAL
● Weight evenly ● Weight evenly
distributed distributed
● Shoulders ● Shoulders
symmetrical, symmetrical, parallel
parallel with hips with hips
● Can open mouth ● Can open mouth
Palpation Palpation

● Able to shrug ● Able to shrug

shoulders shoulders against
against resistance, non-
resistance, non- tender, warm, no
swelling.
 tender, warm, no ● Muscle size are equal
swelling. in size bilaterally and
● Muscle size were equally strong
equal in size
bilaterally and
equally strong

NEUROLOGIC Inspection Inspection

 Client was Alert ● Alert and awake with

and awake with eyes open and
eyes open and looking at examiner;
looking at client responds
examiner; client appropriately.
responded ● For Posture-Relaxed
appropriately. with shoulders back
 Client appeared and both feet stable.
relaxed with ● For Gait- Smooth,
shoulders back coordinated
and both feet movements; client
stable. alters position
 For Gait- Smooth, occasionally.
coordinated ● For speech- Clear
movements; client with moderate pace’
altered position ● For clarity and
occasionally. content- Expresses
 For speech- Was full and free flowing
Clear with thoughts during
moderate pace’ interview
 For clarity and ● For judgement-
content- Answers to questions
Expressed full and are based on sound
free flowing rationale.
thoughts during
interview
 For judgement-
Answers to
questions are
based on sound
rationale.

12 Cranial CN I Olfactory CN I Olfactory
Nerves
 Client Identified ● Identifies scent
scent correctly correctly with each
with each nostril nostril
CN II-IV and VI CN II-IV and VI

 The client was ● The client is able to

able to read the read the words on the
words on the paper placed 12
paper placed 12 inches away from her
inches away from eyes.
her eyes.
CN V Trigeminal CN V Trigeminal

●The Client was able to ● Eyelids blink

blink Eyelids bilaterally bilaterally and
and identify light touch, identifies light touch,
dull and sharp sensations dull and sharp
to forehead, cheeks and sensations to
chin. forehead, cheeks and
chin.
CN VII Facial CN VII Facial

 The client was ● Client can smile,

able to smile, frowns, shows teeth,
frown, show teeth, blows out cheeks,
blow out cheeks, raises eyebrow and
raise eyebrow and closes eyes tightly,
close eyes tightly, face movements are
face movements symmetrical
were symmetrical
CN VIII Acoustic CN VIII Acoustic

 Client heard on ● Can hear on both

both ears when ears when whispered
the examiner a two-syllabus word.
whispered a two-
syllabus word and
verbalized back
the same word.
CN IX Glossopharyngeal CN IX Glossopharyngeal

 Gag reflex was ● Has gag reflex

present
CN X Vagus CN X Vagus

 ● Bilateral, symmetrical
rise of soft palate and
uvula, gag reflex
present.
CN XI Spinal Accessory CN XI Spinal Accessory

 Bilateral, ● Strong, symmetrical

symmetrical rise of contraction of
soft palate and trapezius muscles
uvula, gag reflex and
present. ● Sternocleidomastoid.
CN XII Hypoglossal CN XII Hypoglossal

 Had a ● Symmetrical tongue

Symmetrical with smooth outward
tongue with movement and
bilateral strength.
smooth outward
movement with
bilateral strength
 Review of System

System

The client denied of skin rash, hives,

sensitivity to sun exposure, tightness,

nodules or bumps, color changes in nails.

Integumentary
Client stated that she had a vertically dry

scar on her abdomen medially from the hyper

gastric region to the upper umbilical region.

HEAD, EYES, EARS, NOSE AND Head: The client verbalized that she has

THROAT: never had any head injury.

Eyes: the client stated that her eyes were

good and she does not feel changes in vision.

Ears: The client stated that she does not

have ear infection and different discharge.

Nose and Sinuses: the client verbalized that

she does not have frequent colds, nasal

stuffiness, discharge, hay fever and

nosebleeds.

Throat (or mouth and pharynx): the client

verbalized that she does not have sore

tongue, bleeding gums, sores in the mouth,

 dry mouth, frequent sore throats, hoarseness

or constant feeling of a need to clear the

throat when nothing is there.

NECK:

The client verbalized that she doesn’t have

lumps or any nodules in the neck area.

The client verbalized that she does not have

bad breasts which are painful with hair or

BREAST:
enlarged breasts.

The client stated that she does not have

breathing difficulties or even coughing

RESPIRATORY:

Client does not use sternocleidomastoid

muscles to breath

“the client verbalized that I have an acute

abdominal pain that started after incision was

done on my abdomen”

GASTROINTESTINAL:
 GENITOURINARY: The client verbalized that she urinates

frequently when she drinks well and currently

has no difficulty urinating

Client stated that she had no difficulty in

walking
MUSCULOSKELETAL:

The client said she likes smiling and

being alert in class and wants to become a

NEUROLOGIC:
doctor when she grow up

HEMATOLOGIC: The client stated that she does not have

problems with blood like bleeding.