PHYSICAL EXAMINATION / HEALTH ASSESSMENT

ABNORMAL
SYSTEM NORMAL FINDINGS PATIENT FINDINGS
FINDINGS
GENERAL SURVEY
Blood Pressure Systolic: 120-140 Increased or 140/100 mmHg
mmHg Decreased BP
Diastolic: 60-90
mmHg

Pulse Rate Increased or

60 – 100 bpm
Decreased

Temperature Increased or
36.5 – 37.5 degrees
Decreased 96 bpm
Celsius

O2 Saturation
95 - 100 % Below 95 %

Respiratory Rate
12-20 cpm Increased or
38.0 °C
Decreased
 Pain Score 0 7-10

Weight ----- ----- 95%

Height ----- Dwarfism,

gigantism

BMI 18.5 -24.9 Overweight: 25.0 - 24 cpm

29.9
Obesity: ≥ 30
Morbidly obese:≥ 40

Observed Behavior and Alert, oriented, well Lethargic/coma, 8/10

Appearance developed for age, delayed

appropriately development; 63 kg

dressed for season. unkempt, dress

inappropriate to 183 cm

situation.

19.68
 - Received patient lying
on bed, alert, oriented,
well developed for age,
dress for season.
SKIN, HAIR, AND NAILS
Skin Evenly colored skin Pallor, cyanosis, - The patient has jaundice
tones without jaundice, and with uniform skin color all
unusual or acanthosis throughout the body
prominent nigricans. Rashes except under his axillae,
discolorations. and redness. which is darker. His skin
Smooth, intact, and Presence of lesions. folds and axillae were
no reddened areas. Dry skin, rough and moist. Skin temperature
No lesions. Warm flaky. Cold clammy was uniform in all
temperature. Mobile skin. Decreased or extremities when touch.
with elasticity and poor skin turgor. Warm to touch.
returns to original Edema.

Hair shape quickly.

Unevenly - Upon inspection, hair
Evenly distributed. distributed, signs of was short and dark in
alopecia color. His hair was thin
 and evenly distributed.

Scalp

Dry
Moist or oily. No (+) lesions
presence of scars. (+) dandruffs, lice No infection or

Free from lice and (+) infestations were noted

tenderness,
dandruff. No palpable mass upon inspection and

tenderness or palpation of the patient's

masses upon hairline and no dandruff

palpation. was noted on patient's

scalp, no lesions, lumps,
or masses upon palpation.
NAILS Nails are clean, Pink Dirty, broken, - Clubbing of nails was
tones, 160-degree Spoon nails, noted on patient. Upon
angle between the Thickened nails palpation, nail base
nail base and the was firm and
skin, Nails are hard fingernails had a rough
and immobile, Nails texture. Epidermis
are smooth and firm surrounding the nails
was intact and no
 lesions were noted.
Nails were long, dirty
and untrimmed.
Toenail surface was
slightly curved and
rough.
Face Symmetrical. No Asymmetrical, - Skull was rounded
involuntary presence of and normocephalic.
movements. involuntary Symmetry in
movements anatomy of face
was noted.
HEAD, NECK, AND
CERVICAL LYMPH NODE

Skull is generally (+) tenderness - Head is round in shape,

Head
round. No (+) lesions no tenderness noted upon
tenderness upon palpation. No lesions.
palpation.

Neck No lesions, masses (+) lesions No lesions and swelling

present. Able to (+) masses noted. Patient is able to
move neck freely
 Unable to move freely move her neck.
neck freely
Cervical Lymph Nodes Unable to palpate or Enlarged nodes, No enlarged or hard
see nodes able to palpate or nodes noted, nodes are
see nodes, unable to palpate.
tenderness, firm,
hard nodes
MOUTH, NOSE, AND SINUS

Mouth
No plaque and caries Presence of plaque
Teeth were shiny and
a. Teeth
noted and dental caries,
yellow in color.
tooth loss

Pink and moist, no (+) lesions, dry

b. Oral mucosa Oral mucosa is pale and
lesions noted (+)lesions,
dry. No lesions were
bleeding, swelling
noted.
Pink and moist, no
Pale, dry, bleeding
c. Gingiva bleeding, swelling Gingiva is pale and dry.
and lesions noted.
and lesions noted. No lesions and bleeding
noted. No inflammation
noted.
Hydrated, not dry,
 d. Lips symmetrical Cracked, pale, with
fissures, and Outer lips were brownish
cyanosis. pink and were dry.
Pinkish, no lesions
e. Tongue noted With lesions,
fissures, Pale, dry, & longitudinal
ulcerations, pale, fissure were noted.
dry, asymmetrical.
Positioned in the
f. Uvula midline, no swelling
Not in midline
and lesions noted.
position. With
Positioned in the midline.
swelling and
Pink and symmetric. Pinkish in color. No
lesions.
g. Tonsils 1+. No exudate, swelling and lesions
swelling, or lesions noted.
Red, enlarged, and
noted.
covered with
Pink and symmetric. 1+
exudate.

Nose Nasal mucosa is dark (+) lesions, swelling Upon inspection, external
pink, moist, and free and tenderness nose was symmetrical. No
of exudate. Absence abnormal discharges or
of lesions, no flaring were noted. Also,
 swelling and the nose was with uniform
tenderness noted. color with facial skin.
Nasal septum was intact
and in midline.

Sinuses Frontal and maxillary Tender to palpation. Frontal and maxillary

sinuses are sinuses are nontender to
nontender to palpation, no crepitus is
palpation, no evident.
crepitus is evident.
EYES AND EARS
Eyes
Both have even Greyish, uneven a. Iris are black in
a. Iris
colors colors color.

Cloudy white Yellowish, red b. Sclera is cloudy

b. Sclera
white in color.

Moist Dry
c. Cornea c. Cornea is moist.

Equally round and Unequal, non

d. Pupils d. Both pupils are
reactive to light reactive to light
equally round,
 accommodation reactive to light.

Evenly distributed, Unevenly e. Eyelashes are

e. Eyelashes curls outward distributed, curls evenly distributed
inward and curls outward.

No lesions, non
(+) lesions, f. No lesions noted
f. Eyelids tender
tenderness and the skin is
intact.
(+) earwax, aligned, Presence of - Ears are aligned and
Ears no palpable mass, palpable mass clean, earwax was
nom tender (+) tenderness noted. No palpable
masses noted and
non tender.
LUNGS AND THORACIC Symmetrical chest (+) adventitious The skin over the
REGION expansion, scapula sounds posterior thorax was
are symmetrical and (+) Labored intact and uniform in color
prominent. Produces breathing with the rest of the body.
a resonant sound Respiratory rate is Crackles were noted upon
when percussed. not within normal auscultation.
No adventitious limits
 sound. The ratio of
anteroposterior
diameter to the
transverse diameter
is 1:2. No retractions
or bulging of ICS are
noted.
CARDIOVASCULAR
Heart and Neck vessel
Pulse is not visible Bounding, visible Pulse is not visible
-Neck vessels
(-) distention pulse (-) distention
a. Jugular veins
(-) protrusion at > (+) distention (-) protrusion at > 45
45 degrees (+) protrusion at degrees
>45 degree

No blowing and (+) Blowing and No blowing and swishing

b. Carotid arteries
swishing sounds swishing sounds sounds
2+ pulse Pulse strength at 0, 2+ pulse strength
1+, 3+, and 4+

-Heart Audible heart sound Audible heart sound

Inaudible heart
Absence of extra Absence of extra heart
sound. Heart rate is
 heart sounds not within normal sound
(-) lifts limits (-) lifts
(-) heaves (+) lifts (-) heaves
(-) murmurs (+) heaves (-) murmurs
(+) murmurs
BREAST AND LYMPHATIC

a. Breast Symmetrical Asymmetrical, peau Symmetrical

Round and d'orange Round and flat
pendulous (+) edema Smooth
Smooth (+) masses (-) Edema
(-) Edema (+)redness, (-) masses
(-) masses swelling, and (-) redness, swelling, and
(-) redness, swelling, lesions lesions
Nipples and lesions
Nipples are equal in size
Nipples are equal in Retracted nipple

size and dimpling

ABDOMEN Pale coloration Purple, jaundice Upon inspection,

Redness distended abdomen and
Pink, bluish, ascites was noted.
 silvery white Dark, bluish pink Abdomen was supple
striae striae when palpated. Size of
abdomen was observed to
Umbilicus is located be not appropriate for
Deviated umbilicus
midline patient's body. Abdominal
girth of 35 inches was
taken. Caput medusae
noted on the skin of the
abdomen.
Peripheral Vascular - Extremities are - Extremities - Extremities are
bilaterally are bilaterally
symmetrical assymetrical symmetrical

- Extremities are - Extremities - Extremities are

equally warm have unequal equally warm to
to touch temperature/ touch
cold to touch

- Extremities - Extremities - Extremities have

have equal have unequal equal bilateral pulse
bilateral pulse bilateral pulse strength
 strength strength

- Pulse - Pulse strength= 2+

- Pulse strength
strength= 2+ is diminishing
(1+) or
bounding
(4+) - Capillary refill time= 4s
- Capillary refill
time= 2s
Capillary refill time= (+) edema
(-) edema
>2s (-) prominent venous
(-) prominent
(+) edema patterns
venous patterns
(+) prominent
venous pattern
MALE GENITALIA
PUBIC HAIR Pubic hair is coarse. Absence or scarcity Pubic hair is coarse.
of pubic hair.
Pediculosis pubis.

PENIS With rashes,

Skin of penis is Skin of penis is wrinkled
lesions, or lumps.
wrinkled and hair- and hair-less and free of
Tender to palpation.
less and normally rashes, lesions, or lumps.
Chancres,
 free of rashes, hypospadias, and Penis is non-erect soft,
lesions, or lumps. discharges noted. flaccid, and non-tender.
Penis is non-erect Circumcised. Urinary
soft, flaccid, and meatus is the center and
non-tender. is slit like and free of
Circumcised or discharges.
uncircumcised.
Urinary meatus is
the center and is slit
SCROTUM
like and free of
Enlarged scrotal sac
discharges.
from fluid, blood, or
Medium size & round.
tumor. With rashes,
Varies in size and Scrotal skin is thin and
lesions, and
shape. Scrotal skin is rugated. Non-tender
inflammation.
thin and rugated.
Non-tender

Anus and rectum (-) Lesions and (+) lesions (-) Lesions and rashes
rashes (+) ulcers (-) fissures
(-) fissures (+) fissures (-) redness
(-) redness (+) redness
 Musculoskeletal Both upper Extremities are Both upper extremities
extremities are equal unequal in size are equal in size.
in size.

(-) tenderness Swollen and (-) tenderness

(-) muscle enlarged joints (-) muscle spasms

spasms (+) tenderness

(+) muscle spasms
Neurologic

Level of Consciousness Alertness, responds Presence of GCS=15. Patient is

to vocal stimuli fasciculations, tics lethargic, responds to
No fasciculations, and tremors vocal stimuli, responds to
tics, or tremors are questions, and responsive
noted. upon interview due
condition.

Sensory Nerve Assessment Altered perceived

Client correctly Client correctly identifies
sensations. Absent
identifies light and light and sharp
or decreased DTR.
sharp sensations. sensations. Correctly
Abnormal reflex
Correctly identifies identifies area touched.
responses.
area touched. DTR=2+. Elbow flexes
DTR=2+. Elbow and contraction of the
flexes and biceps muscle is seen or
contraction of the felt. Could flex and
biceps muscle is position forearm in
seen or felt. Could supine. Elbow extends
flex and position and triceps contracts.
forearm in supine. Knee extends and
Elbow extends and quadriceps muscle
triceps contracts. contracts. Reflexes are
Knee extends and normal.
quadriceps muscle
contracts. Reflexes
are normal.