PHYSICAL ASSESSMENT
SKIN
Patient’s skin is brown and is generally uniform except in areas exposed to the sun. There is no edema and skin temperature is
within normal range. When pinched, skin springs back to previous state.
HAIR
Patient’s hair is evenly distributed. It is thick, silky and resilient. There are no infections or infestations.
NAIL
Patient’s nails have convex curvature. They are long and dirty. They are smooth, highly vascular and pink. They have intact
epidermis and for capillary refill test, pink color returned after 2 seconds.
SKULL AND FACE
Patient’s skull is rounded (normocephalic and symmetric, with frontal, parietal, and occipital prominences), has smooth skull
contour. Patient’s face is smooth, has palpebral tissues equal in size, and has symmetric nasolabial folds. It has also symmetrical facial
movements.
EYES AND VISION
Patient’s hair in the eyebrows is evenly distributed and skin intact. Her eyelashes are equally distributed and curled outward. Her
eyelids close symmetrically. When her eyelids open, there’s no visible sclera above the cornea, and upper and lower borders of cornea are
slightly covered. Her palpebral conjunctiva is slightly pale. There is no edema or tenderness over lacrimal gland. Her cornea is
transparent, shiny and smooth; details of the iris are visible. Client blinks when the cornea is touched, indicating that the trigeminal nerve
is intact. Her pupil constricts when illuminated. Both eyes coordinate, move in unison, with parallel alignment.
EARS AND HEARING
Patient’s ear has the same color with her skin. They are symmetrical. The auricle is aligned with the outer canthus of the eye,
mobile, firm, and not tender; pinna recoils after it is folded. She can hear clearly in both ears.
NOSE AND SINUSES
Patient’s nose is symmetric and straight. There are no discharges or flaring. It is not tender and has no lesions. Air moves freely as
the client breathes through the nares. Nasal septum is intact and in midline.
MOUTH AND OROPHARYNX
Patient’s lips have uniform pink color, soft, moist, have smooth texture. She can purse her lips. There is black discoloration of the
enamel and has missing teeth. Her tongue can move freely. Her tonsils are pink and smooth.
NECK
Patient’s neck muscles are equal in size, has limited range in motion, and painful when moved.
THORAX AND LUNGS
Patient’s spine is vertically aligned. Her spinal column is straight, right and left shoulders and hips are at same height. Her
posterior thorax’s skin is intact and has uniform temperature. Her chest wall is intact, no tenderness; no masses.
THE CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEMS
There are no pulsations in the patient’s aortic and pulmonic areas, and in the tricuspid area. There is no sound heard upon
auscultation of the carotid artery. The patient’s peripheral pulses have symmetric pulse volumes and full pulsations. Her limbs are not
tender and are symmetric in size. Her skin color in the hands is pink, skin temperature not excessively warm or cold, no edema, and skin
texture resilient and moist. For capillary refill test, pink color returned after 2 seconds.
THE BREASTS AND AXILLAE
Patient’s breasts are rounded shape, slightly unequal in size; generally symmetric. Skin is uniform in color.
THE ABDOMEN
Patient’s abdomen has unblemished skin, uniform color, flat, and rounded. It has symmetric contour.
THE MUSCULOSKELETAL SYSTEM
Patient’s muscles are equal on both sides of the body. There are no contractures. Muscles are normally firm, have smooth
coordinated movements and have equal strength on each side of the body. Her skeleton has no deformities. Her bones don’t have
tenderness or swelling. Her joints also don’t swell, are not tender, have no crepitation or nodules. They move smoothly.
THE NUEROLOGIC SYSTEM
The patient can recognize common objects. She responds with sense.
THE FEMALE GENITALIA
The patient was not assessed in her female genitalia.
