PHYSICAL ASSESSMENT

Date: February 26 2020

Patient name: Patient X

General survey: Received patient lying on her bed, awake, conscious, coherent with ongoing IV
fluid of D5 LRS 1L x 10 80 cc hook at the metacarpal vein infusing well. The patient was
oriented in time, date, place, person and to her present condition.

Vital sign:

Body temperature: 37.3

Blood pressure: N/A

Respiratory rate: 13 cycles per minute

Pulse rate: 56 beats per minute

PARTS METHODS USED FINDINGS INTERPRETATION

Skin
 Skin turgor  Inspection  moist  Normal
 Palpation  brown in color  Normal
 the skin go back to  Normal
its normal state
after pinching
Head
 Scalp  Inspection  round in shape  Normal
 Hair  Inspection  no presence of  Normal
dandruff, no lice
 Inspection  no nodules or  Normal
masses
 Inspection  black/long hair  Normal
  Inspection  hair is smooth and  Normal
thin

Eyes
 Conjunctiva  Inspection  symmetrical  Normal
 Eyebrows  Inspection  transparent  Normal
 Pupils  Inspection  pinkish in color  Normal
using  black in color  Normal
penlight
 Eyelashes  Normal
 Inspection  Equally
distributed
 Eyelids  Skin intact  Normal
 Inspection  Ability to blink  Normal
 Iris (2-3
 Inspection blinks/minute)  Normal
 Light brown in
color  Normal
External ears
 Inspection  Symmetrical  Normal
 Same color with  Normal
face
 Without lesions  Normal
 The upper point of
attachment is  Normal
leveled to the outer
 Internal ears cantus
 Palpation  Pinna recoil  Normal
Nose
 Inspection  Same color as the  Normal
face
  Peeling of the skin  Normal
 Palpation  No tenderness and  Normal
mass
Mouth
 Lips  Inspection  Moist  Normal
 Teeth  Inspection  Clean, no dental  Normal
caries
 Tongue  Inspection  Pink in color  Normal
 Gums  Inspection  Moist
 More freely  Normal
 Pink in color
Neck
 Trachea  Inspection  Flexed normally
 Palpation  Trachea is in the
 Thyroid middle
 Inspection  Presence of mass  Caused by
and palpation 5 cm bacterial
infection
Chest
 Thorax  Inspection  symmetrical  Normal
and palpation  no presence of  Normal
crackles
 Abdomen  Inspection  no presence of  Normal
 Auscultation mumur
 no lesions  Normal
 no pain during  Normal
palpitation
 bowel sound:3bpm  Normal
Upper Extremities

 Shoulder
  Inspection  moves freely  Normal
 symmetrical to  Normal
 Arm both left and right
 Inspection  moves freely  Normal
 right and left arm  Normal
are symmetrical
 Hands  no lesions  Normal
 Inspection  symmetrical both  Normal
 Fingernails left and right
 Inspection  no presence of  Normal
edema
 short nails  Normal
 Capillary bed  3 seconds  Normal
 Pulse refill
 Palpation  Pulse rate- 56bpm  Normal
Lower extremities

 Legs
 Inspection  less hair  Normal
 symmetrical to  Normal
both left and right
 able to flexed and  Normal
extend
 no presence of  Normal
 Feet edema
 Palpation  no mass or lumps  Normal
 Inspection  short nails  Normal
Palpation  no pain during  Normal
palpation