PHYSICAL ASSESSMENT

ASSESSMENT CLINICAL EXAMINATION

General Appearance  Conscious, well-oriented of her present condition and does not show interest with the interview in answering
every question instantaneously.

 Vital Signs were assessed with a temperature of 36.6 centigrade, pulse rate of 86 beats per minute, respiration
rate of 16 breaths per minute and blood pressure of 80/60 mmHg.

 The patient is hypotensive with a blood pressure of 80/60 mmHg.

 Does not showed potential signs of emotional distress.

 Physically, the patient’s body built/physical appearance is appropriate to her age.

 The patient is relaxed, has an erect posture and coordinated by body movements, can freely move, flex and
extend her extremities, doesn’t use any assistive device and can voluntarily move.

 The patient’s mood is appropriate to the situation and has an appropriate response.

 Upon assessment, the nails look kempt and well-trimmed.

 (-) Frail (-) Robust (-) Pale (-) Cyanotic (-) Pain (-) Emaciated (-) Fairly Nourished (-) Respiratory Distress

Skin  (-) Cyanosis, (-) Jaundice, (-) Dry, (+) Moist, (+) Pallor, (-) Cold, (+) Warm, (-) Poor Turgor, (-) Rashes, (-) Nail
Clubbing, (-) Mass, (-) Lesions, (-) Easy Bruising.

Hair  Black, fine, short bob cut, evenly distributed across scalp (-) dandruff, (-) Lice
  (-) Headache, (-) Lump, (-) Hair Loss, (-) Hydrocephalus

Nails  Fingernails and toenails look kempt, (-) Pallor (-) Cyanosis with good capillary refill of 2-3 second.

Hematologic  (-) Pallor with good capillary refill of 2-3 seconds

Face  Symmetrical

Eyes  Eyelids (-) edema (-) redness, (-) Discharge, (-) Discoloration, (-) Lesions (-) Nodules, Lids close symmetrically
 Conjunctiva – (-) Lesions, pale, (-) discharge
 Cornea - transparent, shiny, visible details of iris
 Sclera – white

Pupil  Black in color, constricted, equally round and reactive to light and accommodation (2mm)

Extra ocular muscle test  Both eyes coordinated, move in unison with parallel alignment

Visual acuity  Able to read 20/20, (-) use of eyeglasses

Ear  Symmetrical, equal in size, color same as facial skin, pinna recoils after it is folded, (-) inflammation (-) lesions,
can hear normal conversation, (-) nodule on the right lobule of external auricle

External ear canal  Minimal cerumen; no complaints of pain.

Nose  (-) discharge, (-) pain, (-) swelling, (-) flaring, symmetrical
Mouth and Throat  (-) Lip and cleft palate, (-) Inflammation, Pinkish lips, (-) pigmentation, Symmetrical contour, ability to purse lips,
(-) lesions
 Teeth - (-) Dentures, (-) Dental carry, 32 teeth present
 Gums - (-) Soreness (-) Lesions, pinkish, smooth, moist, with clearly defined margins at each tooth.
 Tongue – (-) lesions, smooth posterior surface, slight rough anterior surface, easily move in all directions, and
lie to the front at rest
 Oral mucosa: smooth, moist, (-) lesions (-) odor
 Oropharynx and Uvula: pink, moist, (-) inflammation, (-) exudates
 Tonsils: pink

Neck  Head centered, no discomfort during movement, (-) lumps, with good voice modulation

Trachea  equal spaces in both side of the neck

 (-) Enlarged thyroid, gland ascends during swallowing, (-) Nodules, (-) Masses, with good voice modulation
Thyroid

Chest and Lungs  Symmetrical chest expansion, trunchal in shape; RR:16 cycles per minute
 Palpation: (-) Mass, (-) Lumps, equal tactile and bilateral symmetry of vocal fremitus
 Percussion: resonant
 Auscultation: (-) Crackles, (-) Wheezing, (-) Pleural friction rub, Bronchovesicular

Breast  Symmetric
 Skin uniform in color as that of the abdomen and back
 Widened and bilaterally the same. Its color is dark brown
 (-) inverted, (-) edema
 (-) Discharge, (-) Ulcer, (-) Dimpling, (-) Mass/Nodule, (-) Tenderness

Heart  Adynamic precordium, (-) Precordial bulging

 P- (-) Heaves, (-) Thrills
  (-) Precardial friction rub, (-) Murmur, (-) Skipping of heart sounds; HR- 86 beats/minute
 (-) Irregular rhythm (-) Bradycardia (-) Tachycardia (-) Murmur

Abdomen  Linea Nigra apparent, starting from the fundus to symphysis pubis, light brown.
 (-) Scar, (-) Pulsation, (-) Hyperactive bowel sound, (-) Tenderness, (-) Palpable Mass (-) Enlargement ()
Others_____ () FHt______

Genitalia  (-) Scar, (-) Lesions, (+) Discharge bright red ( ) Others_____ ( ) IE_____

Anus  (-) Discharge, (-) Lesions, (-) Pain, (-) Swelling, (-) Varicosities, (-) Hernia, (-) Hemorrhoid

Upper and Lower  (-) Deformity, (-) Asymmetry, (-) Mass, (-) Lesions, (-) Pain, (-) Thready/Weak Pulses, (-) Cold, (+) Warm, (-)
Extremities Edema, (-) Swelling, (-) Discoloration, (-) Pallor, (-) Cyanosis

Cranial Nerves  I (-) Anosmia/Loss of sense of smell.

 II, III (-) Blind, (-) Papilledema, (-) Tonic Pupils
 IV, VI (-) Strabismus, (-) Nystagmus
 V (-) Absent corneal reflex/blink reflex
 VII (-) Lid lag, (-) Lip Lag, (-) Facial Asymmetry
 VIII (-) Deafness
 IX, X (-) Dysphagia, (-) Hoarse Voice, (-) Absent gag reflex
 XI (-) Atrophy, (-) Fasciculation, (-) Weakness
 XII (-) Dysarthria, (-) Atrophy, (-) Fasciculation.

Motor Exam  (-) Tremors, (-) Fasciculation, (-) Chorea, (-) Tics, (-) Atrophy, (-) Spastic, (-) Rigid, (-) Flaccid, (-) Unsteady gait,
(-) Ataxia, (-) Weakness on right hand fingers