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. PHYSICAL EXAMINATION

Name of Patient: SM Gender: Female

Age: 77 y/o Address: San Agustin Norte Arayat

Glasgow Coma Scale (GCS): 15 (E4V5M6) Temperature: 36.1C

AREA OF ASSESSMENT ASSESSMENT

TECHNIQUES

NORMAL FINDINGS ACTUAL FINDINGS REMARKSAREA OF ASSESSMENT ASSESSMENT

TECHNIQUES

NORMAL FINDINGS ACTUAL FINDINGS REMARKS


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General Survey

Describe body built Inspection Arm span equals to height,

crown to pubis equal to length

from pubis to sole

Height and weight is

proportional.

Normal

Observe height and

weight in relation to

clients age

Inspection Proportionate, varies with

lifestyle

Height and weight is

appropriate to clients age.

Normal

Posture and gait Observation Relaxed, erect posture;

coordinated movement

Unable to assess the clients

posture and gait due to his

decrease mobility

Not examined

Describe over allhygiene and grooming in

relation to the persons

activities prior to the

assessment.

Inspection Clean, neat Client is neat and wearingnew and clean clothes during

assessment.

Normal

Note for body and

breathe odor in relation

to the persons activities

prior to the assessment.

Inspection No body odor or minor body

odor relative to work or

exercise; no breath odor

No body odor and no breath

odor

Normal

Mental state

Identify signs of distress Observation No distress noted Sometimes client looks

agitated because of the pain

Deviation from normal


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he is experiencing.

Note obvious sign of

health or illness

Observation Healthy appearance Sometimes client is frowning

maybe because of pain.

Deviation from Normal

Assess clients attitude Observation Cooperative, able to follow

instructions

Answers in our questions are

appropriate; cooperative

Normal

Describe clients affect or

mood

Observation Appropriate to situation Clients mood and affect is

appropriate to situation.

Normal

Assess appropriateness

of clients responses

Observation Appropriate to situation Answers of our client in our

questions are appropriate.

Normal

Describe quantity of

speech (amount and

pace), quality (loudness,

clarity, inflection) and

organization (coherence

of thought, over

generalization,

Observation Understandable, moderate

pace; clear tone and inflection;

exhibits thought association

Speech is loud with a clear

diction.

Normal

Listen for the relevance

and organization of

thoughts.

Observation Logical sequence; makes

sense; has sense of reality

Clients answer has sense of

reality.

Normal

Hair


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Inspect the evenness of

growth over the scalp

Inspection Evenly distributed hair With evenly distributed hair. Normal

Inspect hair thickness or

thinness

Inspection Thick hair With thick hair. Normal

Inspect hair texture and

oiliness

Inspection Silky, resilient hair Slightly dull hair because

client hasnt taken a bath

since admitted to hospital.

Deviation from Normal

Note presence of

infections or infestations

Inspection No infection or infestation No observable signs of

infection or any infestations.

Normal

Inspect amount of body

hair

Inspection Variable Variable; hair is evenly

distributed all over the

clients body.

Normal

Skull

Inspect the skull for size,

shaped and symmetry

Inspection Rounded, smooth skull contour Normocephalic and

symmetric

Normal

Palpate the skull for

nodules or masses and

depressions

Palpation Smooth, uniform consistency;

absence of nodules or masses

No palpable nodules, lumps

and masses.

Normal


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Face

Facial features Inspection Symmetric or slightly

asymmetric facial features;

palpebral fissures equal in size;symmetric nasolabial folds

Facial features are

symmetric.

Normal

Symmetry of the facial

movements

Inspection Symmetric facial movements Eyebrows elevate at the same

time; eyes blink and closed

at the same time

Normal

Eyebrows and

eyelashes

Evenness of distribution,

direction of curl and

movement

Inspection Evenly distributed, eyebrows

symmetrically aligned; curled

slightly upward

Eyebrows raise and lower at

the same time; symmetrically

aligned; both eyebrows

curled slightly upward

Normal

Eyelids

Surface characteristics

and ability to blink

Inspection Skin intact, no discharge, no

discoloration;

Lids closed symmetrically

Eyelids skin are intact; no

discharge and discoloration;

eyelids blink symmetrically

Normal


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Conjunctiva

Inspect the bulbar

conjunctiva for color,

texture and the presence

of lesions

Inspection Transparent Bulbar conjunctiva are

transparent; no presence of

lesions; with evident

capillaries

Normal

Inspect the palpebral

conjunctiva for color,

texture and the presence

of lesions

Inspection Shiny, smooth and pink or red Palpebral conjunctiva is

shiny; pinkish in color

Normal

Sclera

Color and clarity Inspection Sclera appears white Sclera is white and clear Normal

Cornea

Color and clarity Inspection Transparent, shiny and smooth Corneas surface is smooth

transparent and shiny

Normal

Iris

Shape and color Inspection Round Round, black in color Normal

Pupils


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Color, shaped and

symmetry of size

Inspection Black in color, equal in size Pupil is round black in color

and equal

Normal

Pupil light reaction and

accommodation

Inspection

Asking the client to look

first at a distant object

and then at a distant

object behind the penlight

Pupils constricts when looking

at near objects; pupils dilate

when looking at far object;

pupil converge when near

object is moved towards nose

Pupils are equally rounded. Normal

Pupils direct and

consensual reaction to

light

Inspection

Asking the client to look

straight ahead, by usingthe penlight and

approaching from the

side, shining a light on

the pupil

Illuminated pupil constricts

(direct response)

Non illuminated pupilconstricts (consensual

response)

Pupil constricts Normal

Visual acuity

Test near vision Asking the client to read

the newspaper held at a

distance of 36 cm

Able to read newsprint Not examined Not examined

Test distance vision Inspection 20/20 vision on Snellentype

chart

Not examined Not examined

Lacrimal gland,

lacrimal sac and


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nasolacrimal duct

Presence of edema Inspection and palpation No edema or tenderness There are no presence of

tenderness and edema.

Normal

Extraocular muscles

Test each eye for

alignment and

coordination

Inspection Both eyes coordinated, move

in unison with parallel

alignment

Both eyes are coordinated

with parallel alignment

Normal

Visual fields

Test for peripheral visual

fields

Inspection

noted

When looking straight ahead,

client can see objects in

periphery

Client can see object using

peripheral vision

Normal

Ear auricle

Color and symmetry of

size and position

Inspection Color same as facial skin,

symmetrical, auricle aligned

with outer canthus of the eye,

about 10from vertical.

Both ear auricle has the same

color with the skin

Normal

Texture, elasticity and

areas of tenderness

Palpation Mobile, firm, and not tender;

pinna recoils after it is folded

There are no areas of

tenderness; no nodules or

lump

Normal

External ear canal

Cerumen, skin lesions, Inspection Dry cerumen, grayish-tan

color; or sticky, wet cerumen

Dry cerumen; no skin Normal


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pus and blood in various shades of brown lesions, pus and blood

Hearing acuity test

Clients response to

normal voice tones

Inspection Normal voices tones audible Voice tones are audible Normal

Perform watch tick test Inspection Able to hear ticking in both

ears


Nose

Shape, size or color and

flaring or discharge fromthe nares

Inspection Symmetric and straight,

uniform color, no discharge orflaring

Symmetric uniform in skin

color; no presence ofdischarge or flaring.

Normal

Presence of redness,

swelling, growths and

discharge of nares, using

the flashlight

Inspection Mucosa pink, clear, watery

discharge, no lesions

Mucosa is pinkish; no lesions Normal

Position of nasal septum Inspection Nasal septum intact and in

midline

Nasal septum in midline Normal

Test patency of both

nasal spectrum

Inspection Air moves freely as the client

breath through the nares

Client can breath freely using

nasal nares.

Normal

Tenderness, masses and

displacement of bone

Palpation No tenderness, masses and

displacement of bone and

No presence of tenderness,

masses and displacement of

Normal


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and cartilage cartilage bone and cartilage

Sinuses

Presence of tenderness Palpation Not tender Sinuses are not tender. Normal

Lips

Symmetry of contour,

color and texture

Inspection Uniform pink color, soft moist,

smooth texture, symmetry of

contour, ability to purse lips

Pinkish color of lips;

symmetry in contour

Normal

Buccal mucosa

Color, moisture, texture

and the presence of

lesions

Inspection and palpation Moist, firm texture, glistening

and elastic texture

Buccal mucosa is moist Normal

Teeth `

Inspect for color, number

and condition and

presence of dentures

Inspection 6 teeth,brownish in color Presence of dental problems Deviation from Normal

due to aging

Gums

Color and condition Inspection No presence of lesions, no

retraction of gums, pink gums

No observable presence of

lesions; without retracted

gums; without bleeding

Normal


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Neck and lymph nodes

Symmetry and visible

mass of the thyroid gland

Inspection Gland ascends during

swallowing but is not visible

No visible masses Normal

Presence of tenderness or

nodules in the lymph

nodes

Palpation Not palpable No nodules or tenderness Normal

Placement of the trachea Palpation Central placement in midline

of neck; spaces are equal on

both sides

In midline of neck Normal

Smoothness and areas of

enlargement, masses or

nodules in the thyroid

gland

Palpation

Asking the client to lower

the chin slightly

Lobes may not be palpable No areas of enlargement,

masses or nodules.

Normal

Skin

Inspect for color and

uniformity

Inspection Varies from light to deep

brown, ruddy pink to light

pink, yellow overtones to

olive; generally uniform except

in areas exposed to the sun,

Brown in color Normal


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areas of lighter pigmentation in

dark-skinned people

Inspect for the presence

of edema.

Inspection and palpation No edema No presence of edema Normal

Observe and palpate skin

moisture.

Inspection and palpation Dry skin and rough dry skin Deviation from Normal

due to aging

Palpate skin temperature. Palpation Uniform, within normal range Skin temperature is within

normal range

Normal

Note for skin turgor of

the client.

Inspection Skin springs back to previous

state; may be slower in elders

Skin turgor is good. Normal

Nails

Inspect fingernail shape

to determine its

curvature and angle

Inspection Convex curvature, angle of

nail plate about 1600

No signs of early clubbing. Normal

Inspect fingernail and

toenail texture

Inspection rough texture Skin is rough Deviation from Normal

due to aging

Inspect fingernail and

toenail bed color

Inspection Highly vascular and pink in

light skinned clients; dark

Pink in color Normal


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skinned clients may have

brown or black pigmentation

in longitudinal streaks

Inspect tissuessurrounding nails

Inspection Intact epidermis No presence of lesions Normal

Perform blanch test of

capillary refill

Inspection Prompt return of pink or usual

color

Skin return to its normal

color

Normal

Posterior Thorax

Shape, symmetry, and

compare the diameter of

the antero posterior

thorax to tranverse

diameter.

Inspection Anteroposterior to transverse

diameter in ratio of 1:2, chest

symmetric

Symmetrically aligned Normal

Spinal alignment Observation Spine vertically aligned Spine is vertically aligned Normal

Breathing pattern Inspection Proper breathing pattern Can breathe properly Normal

Respiratory excursion Inspection Full and symmetric chest

expansion

Chest expands at the same

time.

Normal

Temperature, tenderness,

masses

Palpation Uniform temperature, no

tenderness, no masses

With uniform temperature;

no signs of tenderness or

masses

Normal


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Vocal fremitus Palpation Bilateral symmetry of vocal

fremitus, heard most clearly at

the apex of the lungs

Has good vocal fremitus Normal

Percuss the posteriorthorax

Percussion Percussion notes resonate,except over scapula, lowest

point of resonance is at the

diaphragm


Auscultate the posterior

thorax

Auscultation Vesicular and

bronchovesicular breath

sounds

Breath sounds are clear Normal

Anterior thorax

Breathing pattern Inspection Quiet, rhythmic, and effortless

respirations

No problems with regards to

respiration of the client.

Normal

Temperature, tenderness,

masses

Palpation Uniform temperature, no

presence of masses and

tenderness

No observable presence of

masses

Normal

Respiratory excursion Inspection Full symmetric excursion;

thumbs normally separate 3 to

5 cm

Has good respiratory

excursion

Normal

Vocal fremitus Inspection Same as posterior vocal

fremitus; Fremitus is normally

decreased over heart and breast

tissue

Has good vocal fremitus Normal


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Percuss the anterior

thorax

Percussion Percussion notes resonate

down to the sixth rib at the

level of the diaphragm but are

flat over areas of heavy muscle

and bone, dull on areas overthe heart and the liver,

tympanic over the underlying

stomach


Auscultation of the

trachea

Auscultation Bronchial and tubular breath

sounds


Auscultate the anterior

thorax

Auscultation Bronchial and vesicular breath

sounds


Abdomen Normal

Abdominal contour Inspection Flat, rounded(convex) or

scaphoid (concave)

Symmetrical Normal

Enlarges liver or spleen Palpation Liver and spleen must not be

palpated.

Without enlarge liver and

spleen

Normal

Symmetry of contour Inspection Symmetric contour Symmetrical Normal

Abdominal movements Inspection Symmetric movements caused

by respiration

Symmetrical movements Normal


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Vascular pattern Inspection No visible vascular pattern Not visible Normal

Bowel sounds, vascular

sounds and peritoneal

friction rubs

Auscultation Audible bowel sounds,

absence of bruits, absence of

friction rub


Percuss abdominal

quadrants

Percussion Tympany over the stomach

and gas-filled bowels;

dullness, especially over the

liver and spleen, or a full

bladder


Musculoskeletal system Normal

Muscle size, compare themuscles on one side of

the body (arm, thigh,

calf) to the same muscle

on the other side

Inspection Equal on both sides of body Muscle size are equal allthroughout the body.

Normal

Muscle tonicity Inspection Has good muscle tonicity. Normal

Muscle

strength

Inspection Equal strength on each body

side

Has equal muscle strength. Normal

Bones

Normal

structure

Inspection No deformities No observable bone

deformities

Normal

Edema or Palpation No tenderness or swelling Presence of swelling because Deviation from Normal


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tenderness of fracture

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