PHYSICAL ASSESSMENT

A. General Survey: GCS 15 (E4V6M6), Coherent and not in CRD.

B. Vital Signs:
● BP: 140/90
● HR: 73
● RR: 21
● O2: 97%

Assessment Body Part Norms Actual Findings Analysis and

Method Used Interpretation

Inspection and Head Normocephalic Symmetrical,

Palpation without scalp lesions. AS, PPC, no
The sensation is nasoaural dc,
intact over the face. tongue and
No facial asymmetry, uvula midline
muscles of facial
expression intact.

Auscultation Chest No abnormal SCE, no The patient

curvature of the retractions, CBS does not exhibit
spine. Full range of signs of
motion, no muscle respiratory
spasm or tenderness. distress.

Auscultation Heart The external chest is AP, NRRR, no The heart is at

normal in appearance murmurs the normal rate,
without lifts, heaves, regular rhythm.
or thrills. Heart rate
and rhythm are
normal.

Inspection and Abdomen The abdomen is soft, Flat, soft, non- The abdomen is
Palpation symmetric, and non- tender soft, the rectus
tender without muscle is
distention. There are relaxed and no
no visible lesions or discomfort is
scars. elicited during
palpation.

Palpation Extremities No asymmetry or Grossly normal, Normal CRT -

muscle atrophy, full no edema, CRT normal blood
ROM of all joints. < 2 secs volume and
Normal skin perfusion; no
temperature, no edema
edema.

Neuro:
Oriented to 3 spheres
Motor: 5/5 for right extremities; 4/5 for left extremities
Sensory: 100% all extremities
CBG: 232 mg/dl (8 pm)