Physical Examination

Taken upon interview:

T: 36.7 °C
HR: 78 bpm
Vital Signs
RR: 25 cpm
SPO2: 99%
BP: 120/80 mmHg
Patient is awake, and responsive. He is dressed
appropriately to the weather and temperature. Patient
General Appearance and appears weak, noted with facial grimace, reports pain and
Condition discomfort on epigastric area of the abdomen. “Masakit
hiya didi. Dida han pagdara haak dinhi 10/10 an kasakit
pero yana mga 5 nala”, as verbalized.
Skin is brown and dry with evident scars from insect bites.
Hair is black, and evenly distributed. Fingernails are not
Skin, Hair, and Nails
trimmed and finger tips were dirty with capillary refill of
less than 3 seconds. No clubbing noted.
Head is proportional and symmetrically round and in
midline to the client’s body without lesion and no
Head and Neck
tenderness palpitated. Neck is symmetric and no enlarged
thyroid or masses visible.
Eyeballs are symmetrically aligned in sockets with pale
palpebral conjunctivae. Sclera is anicteric and without
Eyes
increased vascularity or lesions noted. Pupils are equally
round and reactive to light and accommodation.
Patient can hear well. Both ears have no lesions and no
Ears
abnormalities detected.
Patient has teeth formation. The lips are normally
symmetrical but is dry and cracked. Nose is patent and
Mouth, Throat, and Nose
uniform in color without deformity. Nasal septum is at the
Sinuses
midline without bleeding and deviation. No discharge,
tenderness and lesions noted.
Soft and not distended as of the date of physical
examination. No rebound tenderness noted. Pain felt on
Abdomen
epigastric area. PRS upon admission, 10/10. Current PRS is
5/10.
Adynamic Precordium. Heart rate obtained at 78 beats per
Heart and Neck Vessel minute. Jugular vein is not distended, bulging or
protruding.
Symmetrical lung expansion. No wheezing and bilateral
Chest and Lungs crackles. With respiratory rate obtained at 25 cycles per
minute.
Genitourinary Patient does not report any problem in terms of urination.
Patient has no contractures. With full pulses in all
Musculoskeletal
extremities. No edema noted.

Dames, Jan Remedios B – Clinical Group D | Physical Examination