Physical Assessment
A .Vital Signs
T: 37°C R: 21 cpm O2 Saturation: 98%
P: 89 bpm BP: 130/80 mmHg
B. General Survey
General Appearance: Patient was wearing a plain loose white shirt and a blue pajamas.
Grooming: Has Unkept hair with clean clothes
Posture: Coordinated Movement
Speech: Clear and Understandable
Level of Consciousness: Conscious
Coherence: Coherent
Emotional Status: Anxious
C. Eyes
• Hair on eyelids are evenly distributed and curled outward
• Discoloration with smooth border eyebrows were symmetrically aligned with eyelashes black in color
• Iris are typically round and evenly colored
• Sclera is moist and anicteric
• Conjunctivae are clear and equal in size and round
• Penlight reflected on exactly same spot on each eye
• Pupils are equally round and reactive to light accommodation
• The pupils of the eyes are black and equal in size. The iris is flat and round
• Cornea is transparent, smooth and shiny and the details of the iris are visible
D. Ears
• Ears are symmetrical; free of abrasions
• Same color as facial skin
• Symmetrical, firm and not tender
• Aligned with outer canthus of eye
• Pinna recoils after it is folded
• Presence of cerumen in both ears
• The auricles are aligned with the outer canthus of the eye
• The auricles are mobile, firm and not tender, no redness an inflammation noted
• Patient hears normally, no reports of tinnitus
• No foul discharges noted
• No reports of tenderness upon palpation
E. Nose
• Septum is at midline, patent
• No discharges noted upon inspection
• Able to smell normally
F. Mouth
• are pale, soft and dry
• Symmetrical in contour
• Mucosa is slightly pale, moist and smooth
• Teeth is yellowish in color
• Gums are moist and firm in texture, slightly pink in color
• Lips are dry, with slightly pale discoloration
• Tongue is centrally located and pinkish, no signs of swelling and lesions noted
• (-) signs of lesions and inflammation noted
• The palate are light pink and smooth while the hard palate has a more irregular texture
G. Skin
• Skin complexion is brown in color, unblemished and with presence of foul odor.
• She has a good skin turgor and skins temperature is within normal limit
• Warm to touch
• Hair not evenly distributed
• Good skin turgor when pinched, skin brings back to previous state within 3secs
• Absence of nodules and masses
• Skin slightly rough with no lesions noted
H. Abdomen
• Skin color of the abdomen is the same with the rest of the body with brown complexion
• Abdomen appears to be round and distended
• Bowel sounds are active
• There is a line of dark pigment on the abdomen (linea nigra)
• No lesions noted
I. Chest
• Symmetrical in shape
• Without lesions and tenderness upon palpation
• No masses palpable
• With Symmetric chest expansion
• Effortless respiration noted
• The spine is vertically aligned. The right and left shoulders and hips are of the same height
J. Neck
• Same color as the rest of the body
• Nodes not palpable
• No tenderness noted
• No distended vein noted
• Neck is symmetrical to head and without bulging muscles
• The neck muscles are equal in size. The client showed uncoordinated head movements with reports of
headache
• The trachea is placed in the midline of the neck
• The thyroid gland is not visible on inspection and the glands ascend during swallowing but are not visible
K. Lungs
• RR is 21 cpm
• Effortless breathing noted
• (-) using of accessory muscles upon breathing
L. Genitals
• Appropriate for age and sexually active
• Able to urinate
• With foul discharges noted
• No presence of lesions and masses noted upon inspection
M. Bowel and Urine Excretion
• Patient was able to defecate 2x a day
• Yellowish in urine color, able to urinate 3-4 times a day
• With no complaints of painful urination
N. Neurological
• Patient is able to utter clear and understandable words and sounds
• Constant salivation observed
• Talks anxious
• Has no eye contact observed
• Able to show appropriate expressions to specific situations
• Able to point objects and call attention
O. Extremities
• Equal size on both sides of the body
• Normally firm and smooth
• With coordinated movement noted
• With capillary refill of 3 sec
• No observable bone deformities
• Swelling of ankles and feet noted
