PHYSICAL ASSESSMENT

Name: Czarina Joyce Javier

Age: 27 Vital Signs:
Height: 411 T: 37.2 C
Weight: 60 kg PR: 73 bpmBMI: 27.03
RR: 18 cpm
BP: 120/80 mmHg
BODY PARTS TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS
ASSESSED
GENERAL SURVEY:
Body built Inspection Proportionate (Ectomorph, Mesomorph NORMAL
Height & weight Mesomorph, Endomorph)

Posture & gait Inspection Stands comfortably erect, normal Erected due to abdominal pain. Deviation from normal due to e
posture, walks normally posture associated with abdomin
Overall hygiene & Inspection Well-groomed, clean Neat. Well-groomed and clean. NORMAL
grooming
Physical deformities & Inspection No physical deformities, no signs of No physical deformities and no signs NORMAL
signs of health or illness illness of illness

Level of consciousness Inspection Responsive; responds to questions Responds well to questions correctly NORMAL
correctly and clearly and clearly.
Emotional status Inspection Appropriate to the situation; happy, Appropriate to the situation; happy, NORMAL
normal, relaxed normal, relaxed
Language & Inspection Understandable; exhibits relevance and Answers in a logical manner. NORMAL
communication organization of thoughts
SKIN:
Skin color, uniformity, Inspection Color varies from light to dark brown, Her skin color is uniformly light NORMAL
presence of edema uniform in color, unblemished skin, no brown in color. No presence of
signs of edema edema.
Skin lesions Inspection No lesions or abrasions. Freckles, Has 3 moles in the face. No lesions NORMAL
birthmarks & moles are normal or abrasions.
Skin moisture & Palpation Moist where the skin folds and in Moist where the skin folds and in NORMAL
temperature axillae axillae
 Skin turgor Inspection Skin springs back when pinched; < 3 Springs back a second after pinched NORMAL
seconds is normal
NAILS:
Fingernail plate shape Inspection No clubbing or spooned; convex No clubbing or spooned and has a NORMAL
curvature, about 160 degrees convex curvature
Fingernail color & Inspection & Pinkish in color, highly Pinkish in color, highly vascular, and NORMAL
texture Palpation vascular, smooth has smooth texture
texture
Tissues surrounding the Inspection Intact epidermis Intact epidermis NORMAL
nails
Capillary refill Inspection & Prompt return of usual color when Promptly return to pinkish color a NORMAL
Palpation blanch test is performed second after blanch test
HEAD:
Evenness of hair growth Inspection Normal hair growth, thick hair, evenly Normal hair growth, thick hair, NORMAL
distributed, silky evenly distributed, silky
Scalp Inspection Pinkish scalp; no dandruff, lesions, Pinkish scalp; no dandruff, lesions, NORMAL
nodules or tenderness nodules or tenderness
Presence of infection or Inspection & Infection or infestations not present No infection or infestations NORMAL
infestations Palpation
Skull size, shape & Inspection Symmetrical Symmetrical NORMAL
symmetry
Facial movements Inspection No involuntary facial movements, Facial movements are symmetrical NORMAL
facial movements are symmetrical
EYES:
Eye condition Inspection Straight, normal and non-protruding Straight, normal and non-protruding NORMAL

Eyebrows Inspection Symmetrically aligned, hair evenly Symmetrically aligned, hair evenly NORMAL
distributed, no scaling distributed, no scaling
Eyelids & Eyelashes Inspection Intact skin, no discharge, eyelids close Intact skin, no discharge, eyelids NORMAL
symmetrically close symmetrically
Ability to blink Inspection Approximately 15-20 involuntary 18 involuntary blinks per minute NORMAL
blinks per minute
 Bulbar conjunctiva Inspection Pinkish or reddish; capillaries Pinkish and capillaries evident NORMAL
sometimes evident
Palpebral Conjuctiva Inspection Shiny, smooth, pink or red in color Shiny, smooth, pink in color NORMAL

Sclera Inspection Sclera appears white White sclera NORMAL

Cornea & Iris Inspection Cornea: transparent & shiny Cornea: transparent & shiny NORMAL
Iris: visible, varies in color Iris: visible, dark brown in color
Pupils Inspection Black in color, equal in size, round, Black in color, equal in size, round,
reactive to light and accommodation reactive to light and accommodation NORMAL
reaction to light
Extraocular muscles Inspection Both eyes coordinated, move in unison Both eyes coordinated, move in NORMAL
and with parallel alignment unison and with parallel alignment
Peripheral visual fields Inspection The client can see the object in the The client can see the object from her NORMAL
periphery. periphery.
Visual Acuity Inspection Near vision: able to read newsprint Distant vision: 125/100 NORMAL
Distant vision: 20/20 Snellen Chart
EARS:
Auricles Color same as facial skin; Color same as facial skin;
Color Inspection Symmetrical; aligned with the outer Symmetrical; aligned with the outer NORMAL
Symmetry & Position cantus of the eye; Recoils back when cantus of the eye; Recoils back when
Texture & Elasticity its folded, mobile and firm its folded, mobile and firm
Pearly grey in color; distal part has Presence of small amount of waxes NORMAL
External Canal Inspection hair follicle; presence of small amount but no redness or discharge
of waxes but no redness or discharge
Hearing Acuity Inspection Normal voice tones audible Normal voice tones audible NORMAL

Watch tick Test Inspection Audible; 1-2 inches from uncovered Audible; 2 inches from uncovered NORMAL
ear ear

NOSE:
 External Inspection Symmetrical and straight; no discharge Symmetrical and straight; no NORMAL
or flaring; uniform in color discharge or flaring; uniform in color
Nasal Septum Inspection Intact and in midline Intact and in midline NORMAL

Patency Palpation Air moves freely in and out of the Air moves freely in and out of the NORMAL
nasal cavities nasal cavities
Nasal cavities Inspection No obstruction, pinkish; clear watery No obstruction, pinkish; clear watery NORMAL
discharge; no lesion discharge
Sinuses Palpation No tenderness or masses No tenderness or masses NORMAL

MOUTH:
Lips Inspection & Uniform in color, soft; moist, smooth Pinkish in color; soft; moist, smooth NORMAL
Palpation texture, symmetrical texture, symmetrical
Buccal Mucosa Inspection Pink in color; moist smooth soft and Pink in color; moist smooth soft and NORMAL
elastic texture elastic texture
Inspection & Central position of tongue and Tongue and frenulum in central
Tongue Palpation frenulum, pink color; moves freely; no position; moves freely; no tenderness NORMAL
tenderness; prominent veins at the base and no nodules.
and no nodules
Teeth Inspection 32 permanent teeth, smooth and white 29 permanent teeth, 1 of which with Deviation from normal due to inc
enamel caries permanent teeth and presence o
with caries.
Gums Inspection & Pink gums, moist firm texture, no Pink gums, moist firm texture, no NORMAL
Palpation lesions, no discharge lesions, no discharge
Palates Inspection Soft: light pink, smooth Soft: light pink, smooth NORMAL
Hard: lighter pink, irregular texture Hard: lighter pink, irregular texture
Uvula Inspection Positioned midline of the soft palate Uvula positioned in midline of soft NORMAL
palate
Pink and smooth; no discharge NORMAL
Tonsils Inspection Pink and smooth; no discharge
Gag reflex is present NORMAL
Gag reflex Inspection Gag reflex is present
 NECK:
Neck movements Inspection Coordinated, smooth movement with Coordinated, smooth movement with NORMAL
no discomfort no discomfort
Neck muscles Inspection Equal strength, muscles equal in size Equal strength, muscles equal in size NORMAL
and head is centered and head is centered
Lymph Nodes Inspection & Not seen and not palpable Not seen and not palpable NORMAL
Palpation
Trachea Inspection and Central placement, midline of the NORMAL
Central placement, midline of the neck
palpation neck
Thyroid Gland Inspection Not visible and glands ascends during Ascends when instructed to swallow. NORMAL
swallowing Not visible
THORAX & LUNGS:
Posterior Thorax: Inspection Anteroposterior to transverse diameter Symmetrical in size NORMAL
Shape & Symmetry in ratio of 1:2; symmetrical in size
Inspection Spine is vertically aligned, spinal Spine is vertically aligned, spinal NORMAL
Spinal Alignment column is straight, right and left column is straight, right and left
shoulders are straight and hips are at shoulders are straight and hips are at
the same level the same level
Color, Temperature, Inspection & Skin intact, uniform temperature, no Skin intact, uniform temperature, no NORMAL
Tenderness & Masses Palpation tenderness and no masses, full and tenderness and no masses, full and
symmetric chest expansion symmetric chest expansion
Respiratory Excursion Inspection Thumbs separates during respiration Thumbs separates during respiration NORMAL

Vocal Fremitus Palpation Bilateral symmetry of vocal fremitus Bilateral symmetry of vocal fremitus NORMAL
when 99 was repeated when 99 was repeated
Diaphragmatic Percussion Resonate lowest point of resonance on Lowest point of resonance on the NORMAL
Excursion the diaphragm diaphragm
Vesicular sound is louder on Vesicular sound is louder on NORMAL
inspiration; Broncho vesicular sound is inspiration; Broncho vesicular sound
Breath Sounds Auscultation equal on inspiration and expiration; is equal on inspiration and
Bronchial sound is shorter on expiration; Bronchial sound is shorter
inspiration on inspiration
 Anterior Thorax: Breathing is effortless; No wheezing. Breathing is effortless NORMAL
Breathing Pattern Inspection Ronchi, crackles or friction rubs heard
Color, Temperature, Inspection & Skin intact, uniform temperature, no Skin intact, uniform temperature, no NORMAL
Tenderness & Masses Palpation tenderness and no masses, full and tenderness and no masses, full and
symmetric chest expansion symmetric chest expansion
Respiratory Excursion Inspection Thumbs separates during respiration Thumbs separates during respiration NORMAL

Vocal Fremitus Palpation Bilateral symmetry of vocal fremitus Bilateral symmetry of vocal fremitus NORMAL
when 99 was repeated when 99 was repeated
Diaphragmatic Percussion Dullness over heart and the liver Dullness over heart and the liver NORMAL
Excursion
Anterior chest: Broncho vesicular and Anterior chest: Broncho vesicular NORMAL
Breath Sounds Auscultation vesicular breath sounds. and vesicular breath sounds.
The same as posterior thorax The same as posterior thorax
Trachea Auscultation Bronchial and tubular breath sounds Bronchial and tubular breath sounds NORMAL
present present
BREAST & AXILLA:

Breast size, shape & Inspection Breast are round, slightly equal in size Breast are round, slightly equal in NORMAL
symmetry and generally symmetric; no size and generally symmetric; no
tenderness, masses and lesions tenderness, masses and lesions
Inspection and Skin is uniform in color, skin is Skin is uniformly light brown in NORMAL
Skin characteristics palpation smooth and intact, no swelling/edema color, smooth and intact, no
swelling/edema
Rounded or oval; light pink to dark Rounded; light pink in color, NORMAL
Areola Inspection brown in color, irregular placement of irregular placement of sebaceous
sebaceous gland on the surface gland on the surface
Round, everted, equal in size, similar Round, everted, equal in size, similar NORMAL
Nipple Condition Inspection in color, soft & smooth, both pointed in color, soft & smooth, both pointed
on the same direction, no discharge on the same direction, no discharge
Axillary, Subclavicular No tenderness, masses or nodules NORMAL
and Supraclavicular Palpation No tenderness, masses or nodules
lymph nodes
 Breast Palpation No areas of tenderness, masses, No areas of tenderness, masses, NORMAL
nodules or nipple discharge nodules or nipple discharge

ABDOMEN:
Uniformly light brown in color; Deviation from normal due to pre
Skin integrity Inspection Unblemished skin; uniform color Presence of lineanigra and lineanigra and striaegravidarum
striaegravidarum pregnancy
Flat, rounded or scaphoid, symmetric Rounded and has symmetric contour NORMAL
Contour and symmetry Inspection
contour
Symmetric movements; peristalsis & NORMAL
Movements Inspection aortic pulsations ONLY visible on very Symmetric movements
thin clients
No visible vascular pattern NORMAL
Vascular pattern Inspection No visible vascular pattern
MUSCULO-SKELETAL SYSTEM:

Inspection & Centered, uniform in color, no Centered, uniform in color, no NORMAL

Sternoclavicular Joint Palpation swelling or masses; No tenderness, no swelling or masses
crepitation or nodules
Cervical, Thoracic & Inspection, Symmetrical, no tenderness, no Symmetrical, no tenderness, no NORMAL
Lumbar Spine Palpation & nodules, no presence of pain nodules, no presence of pain
ROM
Shoulders, Arms & Inspection, Symmetrical, uniform in color, no Uniformly light brown in color. No NORMAL
Elbows Palpation & swelling or masses; uniform in elbow deformities and is able to perform
ROM size & shape, no deformities ROM.
Inspection, Symmetrical, no tenderness, no Symmetrical NORMAL
Wrist Palpation & nodules, no presence of pain; no
ROM deformities
Inspection, Symmetrical uniform in color, no Uniformly light brown in color, same NORMAL
Hands & Fingers Palpation & swelling or masses; No tenderness, no as color of skin, no lesions, swelling
ROM crepitation or nodules or masses
Inspection, Symmetrical uniform in color, no Symmetrical uniform in color, no NORMAL
Knees Palpation & swelling or masses; No tenderness, no swelling or masses; No tenderness,
ROM crepitation no crepitation