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Name: CONRADO L. INTAO III. RLE Group/Section: 05

Clinical Instructor: MA. ZENNETH LA VICTORIA Hospital Area: __EMERGENCY
ROM___________

Physical Examination: 70 points

PHYSICAL EXAMINATION

Individual Date of Birth Gender ID No.

N/A Female
Reason for Assessment:
[ ✔ ] Initial
[ ] Annual
[ ] Other: ______________________________

II. Summary of General Health Status/Health History

[ ] For Initial Assessments only: Summarize concisely the medical events/health history prior to admission to
this facility
The patient’s chief complained of nausea and heartburn until her heartburn was now more of a dull pain
that seemed to spread to her shoulders and experienced shortness of breath. She is having pre pre-existing
condition of hypertension and cultural consideration of risk for hypertension and heart disease.

III. Review laboratory results, allergies and immunities

A. Laboratory results
1. Observation/Findings
[ ] Initial laboratory test results were review on: _____________________ (Date)
[ ] Annual laboratory test results were review on: _____________________ (Date)
[ ] Laboratory test results were within normal limits and required no follow-up action.
[ ] Laboratory test results were abnormal and follow-up action was required: (list abnormal results,
follow-up action, and resolution):

Total creatine kinase (CK) 157 μ/L

Relative index 4.8%
troponin I 2.8 ng/mL

B. Allergies
1. Observation/Findings [ ✔ ] No Known Allergies
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Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
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[ ] When in contact with _____________________________ (environmental factors), the following

reaction occurs:
___________________________________________________________________
[ ] When _________________________________________ (medication) is taken, the following
reaction occurs: ___________________________________________________________________
[ ] When _________________________________________ (food) is consumed, the following
reaction
occurs: _________________________________________________________________________
C. Immunity
1. Observation/Findings Immunizations are current: [ ] PPD [ ] Influenza [ ] Pneumonia [ ] Tetanus
Hepatitis surface antigen tested _____N/A________(date), ________________________(results)
Hepatitis core antigen tested _______N/A_________ (date), ________________________(results)
Hepatitis antibodies tested ______N/A_____________(date), ________________________ (results) [ ]
History of significant tuberculin skin test on ____N/A________________________(date) Exhibits: [ ]
weakness, [✔ ] anorexia (loss of appetite), [ ] weight loss, [ ] night sweats, [ ] low grade fever, [ ]
productive cough, [ ] hemoptysis (blood in sputum). [ ] The above were addressed by the physician on
_______________________________ (date).
HIV status: [ ✔] Unknown [ ] Known

IV. Body Systems Review and Physical Examination:

A. Integument
1. Physical Exam findings
SKIN
[ ] clear, healthy skin [ ] clear, healthy scalp [ ] no problems or deviations assessed
[ ] lesions [ ] rashes [ ] bruises
[ ] wound [ ] drainage [ ] itching
[ ] skin color variation [ ] cyanosis [ ] pallor
[ ] jaundice [ ] erythema [ ] dry, rough texture
[ ] scaling/xerosis [ ] poor tugor [ ] edema
[ ] unusual hair distribution [ ] hair loss [ ] reduced hair on extremities
[ ] hirsutism [ ] hair characteristics [ ] normal
[ ] oily [ ] dry [ ] coarse
[ ] infestation/lice
COMMENT
____N/
A___________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
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____________________________________________________________________________________
_________________________________________________________________________________
STOMA
[ ] Not Applicable
[ ] clean, dry [ ] redness [ ] chronic redness [ ] drainage
[ ] chronic drainage [ ] prolapse
COMMENT
__N/
A___________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________

FINGERNAILS & TOENAILS

[ ] color, shape, cleanliness good [ ] no problems or deviations assessed
[ ] irregularities in surface: _____________________________________________________________
[ ] inflammation around nails: __________________________________________________________
[ ] fungal problem: ___________________________________________________________________
COMMENT
_N.A________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
___

B. Head and Neck

HEAD & NECK [ ✔] No problems or deviations assessed
head motion:
__________________N/A________________________________________________(describe)

[ ] asymmetric head position: _____________________________________________________(describe)

[ ] shrugs shoulders [ ] unable to support head midline & erect [ ] dull, puffy, yellow skin
[ ] periorbital edema [ ] lymph node enlargement [ ] thyroid enlargement
[ ] tracheal displacement
COMMENT
___N/
A___________________________________________________________________________________
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Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
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_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

NOSE & SINUSES [ ] No problems or deviations assessed

[ ] nasal drainage [ ] inflamed [ ] tender [ ] polyps/lesions [ ] edema
[ ] altered nasal mucosa ______________________________________________________(describe)
[ ] absence of frontal sinus glow [ ] right nostril occluded [ ] left nostril occluded
COMMENT
___N/
A___________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

MOUTH & PHARYNX [ ] No problems or deviations assessed

[ ] altered oral mucous membrane: _N/A_____________________________________________ (describe)

[ ] inflammation:
N/A_________________________________________________________________________(describe)
[ ] hoarseness [ ] bruxism (grinds teeth) [ ] loose teeth [ ] decay
[ ] halitosis [ ] excessive salivation [ ] lips dry, cracked [ ] lip fissures
[ ] lip bleeding [ ] gums inflamed [ ] gums bleed [ ] gum retraction
[ ] thick tongue [ ] tongue dry, cracked [ ] tongue fissures [ ] tongue bleeds

Inspect the following:

[ ] inner oral mucosa [ ] buccal mucosa [ ] floor of mouth [ ] tongue
[ ] hard palate [ ] soft palate
Deviations: ______N/A__________________________________________________________ (describe)

[ ] lesions, vesicles:
____N/A_____________________________________________________________________(describe) [
] gag reflex absent [ ] gag reflex hyperactive [ ] poor denture fit or not using
[ ] chewing problem [ ] missing teeth
COMMENT
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Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
Email: info.coc@phinmaed.com +63 (088) 858-3880 / +63 917-376-5105

________N/
A____________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_________________________________________________________________________

C. Eyes and Ears

EYES Visual acuity: ________________N/A______________________________(method & results)
visual fields/peripheral vision present: [ ] right [ ] left
eye tracking present: [ ] up [ ] down [ ] right [ ] left
[ ] corneal light reflex aligned [ ] light reflex misaligned [ ] nystagmus
inspected the external eye structures: [ ] eyebrows [ ] orbital area [ ] eyelids
[ ] lacrimal ducts [ ] conjunctiva [ ] sclera
[ ] cornea
abnormalities: ______N/A_____________________________________________ (specify/describe)
Blink reflex: Right: [ ] present [ ] absent Left: [ ] present [ ] absent
Pupil & iris direct light response: Right: [ ] present [ ] absent Left: [ ] present [ ] absent
Pupil & iris consensual light response: Right: [ ] present [ ] absent Left: [ ] present [ ] absent
Ophthalmoscopic exam: [ ] red reflex obtained red reflex not obtained
Unable to do ophthalmoscope exam due to: ________________________________________________
COMMENT
___________N/
A___________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________

EARS
Inspected the following external ear structures: [ ] auricle [ ] lobule [ ] tragus [ ] mastoid
External ear structure abnormalities: [ ] swelling [ ] nodules [ ] tenderness [ ] discharge
Other abnormalities: __________N/A___________________________________________ (specify)

Otoscopic exam: [ ] cone of light visualized [ ] cone of light not visualized

[ ] tympanic membrane inspected [ ] excessive cerumen
[ ] Unable to examine
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Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
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Simple hearing acuity test: _________N/A_______________________________ (method & response)

COMMENT
___N/
A___________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
__________________________________________________________________________

D. Cardiopulmonary
HEART & VASCULAR [ ] No problems or deviations assessed
Auscultated heart sounds: [ ] S-1 at 5th intercostal space on left
[ ] S-2 at 2nd intercostal space left or right side
apical pulse: 118 BPM____________________ (rate & rhythm)
Jugular venous distention: [ ] present [✔ ] absent
Capillary refill: [ ] > 1 second [ ] < 2 seconds
[ ] PMI palpable – 5th intercostal space medial to left midclavicular line [ ] PMI not palpable

edema: __N/A_____________________________________________________________ (describe)

Blood Pressure
right arm: ____________ (sitting) __________________ (standing) ___________________ (lying)
left arm: ____________ (sitting) __________________ (standing) ___________________ (lying)

The following pulses could be palpated bilaterally: [ ] radial [ ] ulnar [ ] brachial

[ ] femoral [ ] popliteal [ ] dosalis pedis
[ ] posterior tibial
List pulse deviations: _________________________________________________________________
COMMENT
___N/
A___________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________

THORAX & LUNGS [ ] No problems or deviations assessed

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Inspected: [ ] posterior thorax [ ] lateral thorax [ ] anterior thorax

List thorax deviations: _N/A________________________________________________________

[ ] scoliosis [ ] lordosis [ ] barrel chest [ ] intercostal bulging

Auscultated breath sounds: [ ] vesicular sounds at periphery
[ ] bronchovesicular sounds between scapulae or 1st – 2nd intercostal space
lateral to sternum
[ ] bronchial sounds over trachea
Diminished sounds:
____________________________________________________________________________ (describe)

[ ] wheezes [ ] crackles [ ] rhonchi

(Location(s))__________________________________________________________________________
[ ] clear with cough
List breath sound deviations: N/A_________________________________________________________

Respiratory distress: [ ] nasal flaring [ ] use of accessory muscles [ ] SOB [ ] intercostal retraction
Respiratory Rate: _________________________ Pulse oximetry %: _________________________
[ ] apnea monitor
COMMENT
__N/
A___________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
______________________________________________________________________________

E. Gastrointestinal
ABDOMEN [ ] No problems or deviations assessed
Bowel Sounds: [ ] Present in all quadrants
[ ] absent: _N/A________________________________________________ (location)
[ ] hypoactive [ ] hyperactive [ ] tympanic

Abdomen: [ ] flat [ ] distended [ ] soft [ ] firm [ ] rounded [ ] obese

[ ] asymmetry [ ] pain [ ] rebound tenderness

umbilical hernia: __N/A__________________________________________________________

(describe)
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[ ] gastrostomy [ ] jejunostomy [ ] large intestine transverse ostomy [ ] large intestine sigmoid ostomy

[ ] mass: ___N/A________________________________________________________________
(describe)

Skin: _________________________________________ (texture) _________________________ (color)

COMMENT
___N/
A___________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
______________________________________________________________

F. Genitourinary (Gynecological & Breasts)

GENITOURINARY & GYNECOLOGIC [ ] No problems or deviations assessed
External genitalia inspected: [ ] excoriations [ ] rash [ ] lesions [ ] vesicles
[ ] inflammation [ ] bright red color [ ] swelling [ ] bulging
[ ] discharge [ ] inguinal hernia [ ] tight scrotal skin
[ ] large scrotum [ ] phimosis [ ] balanitis
[ ] displace meatus
Testicular self-exam: [ ] independent [ ] needs instructions to complete [ ] unable to complete
COMMENT
___NA______________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
___

BREASTS [ ] No problems or deviations assessed

Deviations assessed in: [ ] size [ ] symmetry [ ] contour [ ] shape [ ] skin color
[ ] texture [ ] venous pattern
Nipple deviations: [ ] retraction [ ] discharge [ ] bleeding [ ] nodules
[ ] edema [ ] ulcerations
COMMENT
_N/
A___________________________________________________________________________________
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Max Y. Suniel St, Cagayan de Oro, 9000 Misamis Oriental
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____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_________________________________________________________________________________

G. Musculoskeletal
[ ] gait abnormalities: _______N/A_______________________________________________________ [
] posture abnormalities: ________N/A____________________________________________________
[ ] impaired weight bearing stance: ____N/A______________________________________________
[ ] bilateral symmetry: N/A_________________________________________________________
[ ] asymmetry: ___N/A______________________________________________________________
[ ] bilateral alignment: __N/A ___________________________________________________________
[ ] misalignment: ____N/A_____________________________________________________________
[ ] decreased ROM: _N/A_______________________________________________________________
[ ] joint swelling [ ] stiffness [ ] tenderness
[ ] Heat:N/A__________________________________________________________________________
[ ] increased muscle tone (hypertonicity):N/A________________________________________________
[ ] hypotonicity: ___N/A_____________________________________________________________
COMMENT
_____N/
A___________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
________________________________________________________________________________

H. Neurologic System
MENTAL & EMOTIONAL STATUS
[ ] alert [ ] aware of environment [ ] impaired consciousness
[ ] Glasgow coma scale score: __________________________
[ ] changed level of consciousness [ ] unchanged level of consciousness [ ] able to communicate
[ ] vocalizes sounds [ ] limited verbalization [ ] non-verbal
[ ] change in communication pattern [ ] unchanged communication

Communication device: ________________________________________________________________

[ ] intellectual impairment unchanged [ ] memory impairment unchanged
[ ] general knowledge deficit unchanged [ ] abstract reasoning unchanged
[ ] impaired association ability unchanged [ ] impaired judgment unchanged
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[ ] changes in mental & emotional status (describe):

___N/A______________________________________________________________________________
____________________________________________________________________________________
_
COMMENT
____N/
A___________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_________________________________________________________________________________

CRANIAL NERVE (CN) FUNCTION

CN I – olfactory [ ] intact [ ] impaired [ ] unknown
CN’s II-III-IV-V – optic, oculomotor, trochlear, abducens (see eye exam)
CN VI – trigeminal (facial sensory & jaw motor) [ ] intact [ ] impaired
CN VII - Facial (symmetry in face expressions & taste) [ ] intact [ ] impaired
CN VIII – Acoustic (see hearing exam)
CN IX – Glossopharyngeal (taste at back of tongue) [ ] intact [ ] impaired
CN X - Vagus (palate movement, “ah” and vocal motor [ ] intact [ ] impaired
CN XI – Spinal Accessory (head motion & shrug) [ ] intact [ ] impaired
CN XII – Hypoglossal (tongue position & motor) [ ] intact [ ] impaired

SENSORY FUNCTION
Touch
[ ] intact
[ ] impaired: ______________________________________________________________ (describe)
Pain
[ ] intact
[ ] impaired: ______________________________________________________________ (describe)

MOTOR FUNCTION
[ ] impaired coordination [ ] fine motor skills impaired
[ ] balance maintained while standing with eyes closed [ ] loss of balance immediate

REFLEXES patellar reflex:

[ ] 0: no response
[ ] 1+ low (normal with slight contraction
[ ] 2+ normal, visible muscle twitch and extension of lower leg
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[ ] 3+ brisker than normal

[ ] 4+ hyperactive, very brisk