Physical Examination

Documentation

For

Patient X

Donnabell L. Dayuday

College of Nursing, Foundation University

NUR 200 – Fundamentals of Nursing

Mr. TJ Bon Boner Agustin

 Date: March 21, 2020

A. Demographic Data
 Name: Cassey Nicole Libron
 Age: 19 years old
 Gender: Male
 Address: Talay, Dumaguete City
 Date of Birth: October 17, 2000
 Place of Birth: Bonawon Siaton, Negros Oriental
 Nationality: Filipino
 Marital Status: Single
 Educational Level: College (Ongoing)
 Occupation: Student
 Usual Source of Income: None
 Informant: Patient
B. Physical Examination
a) General Survey
1. Appearance
 The patient appears to be the same as his reported age. His sexual
development is appropriate. He is alert & oriented with no signs of acute
distress and facial features are symmetrical.
2. Body structure/ mobility
 Weight and and height are within the normal range. His body parts are equal
bilaterally. He stands erect, sits comfortably, gait is coordinated, and his walk
is smooth and well balanced with full mobility of joints.

3. Behavior
 The patient maintains eye contact with appropriate expressions, comfortable
and cooperative. His speech is clear and his clothing is appropriate to the
climate. He looks clean and fit and appears to be clean and well-groomed.

Vitals Signs/Measurement Result

Temperature 36.7°C
Pulse Rate 74 beats per minute
Respiratory Rate 14 cycles per minute
Pain Rating 5 out of 10 where 10 is the most painful and 0
is no pain
Height 5’5 feet
Weight 130 pounds

b) Skin
 The patient’s skin color is even-toned, with pigmentation appropriate for his
genetic background and no obvious lesions, edema or variations in color. Skin
is smooth and dry with minimal perspiration and oiliness and is uniformly
warm. Skin lifts easily and snaps back immediately to its resting position.
c) Nails
 The patient’s nail is well-rounded and convex. It is smooth with a uniform
appearance, no visible lesions, and no signs of dryness, softness, brittleness,
splitting, peeling, ridges, or pitting. Nail beds are pink and capillary refills
within 1-2 seconds after the nail bed is pressed and no tenderness noted. No
signs for clubbing, cyanosis or ingrown as well.

d) Hair
  The patient’s hair is evenly distributed and color matches the patient’s racial
and genetic make-up. Hair is resilient to minimal pressure. The scalp is
smooth and inelastic with even coloration and equal distribution. No visible
lesions and tenderness noted.

e) Head
 The patient’s head is upright and still, the skull is generally round with
prominences in the frontal area anteriorly and the occipital area posteriorly.
No visible lesions and tenderness.

f) Face
 The contour of the patient’s face matches the color of the patient’s body with
no involuntary movements noted. A small amount of pustule is present with
no visible lesions, masses and tenderness noted. Cranial nerves intact as per
positive result in the CN VII test. The patient’s eyebrow is symmetrical in
appearance and no involuntary movement. No visible lesions and tenderness.

g) Eyes
 The patient’s eyelid does not cover the pupil when the eyes are open but it
does partially cover the iris. Eyelashes are normally distributed evenly and
curved outward away from the eyes. Conjunctiva is moist and pink with no
drainage. Sclera appears to be china white. The Cornea is clear and bright
with no signs of opacity or cloudiness. Iris appears to be flat with a round
regular shape and even coloration. Pupil normally appears round, regular, and
of equal size in both eyes.
Visual Acuity Result
OD 20/20 with no mistake
OS 20/20 with 1 mistake
OU 20/20 with 1 mistake

 Extraocular Movement Test - There’s a parallel movement of the eyes

 Visual Field Test – Peripheral vision is working since the patient was able to see the
nurse’s hands while his other eye was covered.
 Pupillary Light Reflex Test – The patient’s direct and consensual light reflex is
intact since both the patient’s pupil constricts as the light shone onto the direct eye.
 Test for Accommodation and Convergence – PERRLA: Pupils Equally Round and
Reactive to Light Accommodation.
 There is accommodation when the patient’s pupil decreased in size as the
vision was transferred from the far object to the nearer one. There is
 convergence when the client’s eyes turned inward as it attempted to look at
the nearer object. Cranial nerves are intact with positive eye test result.
h) Ears
 Auricles are level with each other whose upright point of attachments is in a
straight line with the lateral canthus. It is almost vertical in position and color
is the same as the patient’s face without moles, cysts, deformities or nodules.
No tenderness noted. The meatus isn’t swollen nor occluded. Canal has a little
cerumen that appears to be moist and sticky, the canal is uniformly pink with
tiny hairs in its outer third region. External and internal ear don’t have any
lesions, masses, and tenderness and Tympanic Membrane is gray and
translucent.

 Hearing Acuity
 Whisper’s Test – Patient was able to say the words that the nurse whispered.
 Weber’s Test – Patient heard the vibrations on both ears.
 Rinne’s Test – Air conduction is greater than Bone conduction. (AC=16,
BC=9)
 Romberg’s Test – The client maintains an upright position with only minimal
amount of sway.
i) Nose
 The patient’s nose is smooth, symmetrical, midline and in proportion to other
facial features and the same color with the patient’s face. His septum is
midline and thicker anteriorly than posteriorly. The nasal mucosa is pink and
moist with no lesions. Red glow is present on both sinuses and no tenderness
noted upon palpation.
j) Mouth and Throat
The patient’s mouth is pink, smooth, symmetrical and moist. The mucosa
is glistening, pink, soft, moist, and smooth. The patient’s teeth is present smooth,
white, and in good dentition. Palates are whitish and in dome-shaped. The tongue
is medium or dull red, moist, dorsal surface roughened from the papillae, ventral
surface is smooth, glistening, and highly vascular, saliva is present and lateral
margin is smooth. No lesions or bleeding on his tongue, gums, and mucosa. Uvula
and soft palate rose centrally when the patient says “ah”. Pharyngeal tissue is
normally pink and smooth. No discharges, ulcerations, and enlargement of tonsils
are noted. No limited movement of the patient’s tongue. The gag reflex is intact.
k) Neck
The patient’s neck is symmetrical, without scars, growth, and enlargement of
the parotid glands. The neck has an active ROM (able to do flexion, extension, lateral
rotation and tilting). His thyroid is non-palpable with no visible lesions. Lymph nodes
are non-palpable. His trachea is midline of the neck and is above the suprasternal
notch.
Internal jugular pulsations is rarely palpable, whereas the carotid pulse is palpable.

l) Breast
 The patient’s breast is even with the chest wall, and contains darkly
pigmented nipple and areola, breast skin color is uniform to the patient’s skin.
Skin is intact and smooth, no presence of nipple discharge, swelling, lesions,
scaling or cracks around nipples, dimples, or lumps. No tenderness noted around
the breast and the lymph nodes surrounding the breast and axilla.

m) Respiratory System
Breathing rate and depth is normal, rhythm is regular. Side to side
symmetric chest shape, spine is straight without lateral deviation, scapula is
symmetrical and closely attached to the thoracic wall, no bulging or active
movement of ICS during breathing. No presence of crepitus upon palpation. Faint
symmetrical vibrations is present as the patient speaks. Resonance and Dullness
is heard during percussion and bronchial, bronchovesicular and vesicular sound is
normally heard upon auscultation.
n) Cardiovascular System
Regular heart rate and rhythm, No presence of heart murmur, thrills,
varicose veins, swelling of legs. PMI is heard in the apical pulse.
o) Gastrointestinal System
Color is symmetrical as the rest of the patient’s body. No presence of
scars, bruise, venous patterns, lesions, and striae. Abdomen is soft and non-tender.
Umbilicus is midway between the xiphoid process and the symphysis pubis.
Shape is flat, no signs of inflammation, no discharge and protruding mass.
Swallowing is intact, positive bowel signs. Peristalsis is present, audible sound is
heard 18 times per minute. No rebound tenderness noted.

p) Musculoskeletal System
Muscle strength +5. Movements smooth and coordinated. Gait balanced
and fluid with conformity of phases. No muscular pain/weakness, joint swelling,
soreness, or stiffness, leg cramps, bone defects noted. Negative Romberg’s test.
Able to perform ROM in all areas in the body.