III.

Physical Assessment Findings

Systems Normal Findings P.A Findings

Health history
A. Integumentary
System
➢ No previous history
of skin diseases
➢ No change in mole
➢ Presence of dryness
➢ Absence of pruritus
➢ Absence of excess
bruising
➢ Absence of rashes
or lesions
➢ No change in nails
➢ No history of DM.

➢ Color is brown with

presence of tiny
black spots all over
his body.

Skin
➢ Color is consistent ➢ Pigmentation is
with genetic general.
background and
varies from pinkish
to ruddy tan or from
light to dark brown
➢ Skin temperature is
36.5 degrees
➢ general pigmentation celcius.
id darker in sun ➢ Perspiration on the
exposed areas axilla and skin folds.

➢ skin should be warm

and the temp.should
be equally
 ➢ Perspiration occurs
normally on the face,
hands, axilla and
skin folds in
response to activity.
➢ Rough and wrinkled
Absence of
with even surface.
dehydration
➢ Thin with callus on
➢ smooth and firm,
palms and sole.
with an even surface
➢ uniformly thin over
most of the body.
Thickened callus
areas on palms and
sole
➢ Absence of edema
➢ Excision on right
➢ Skin is elastic
cheek is edematous.
➢ Absence of bruising
➢ Absence of bruising
➢ Absence of lesions
➢ Presence of moles
Hair all over the body.
➢ Color is gray.
➢ Color is gray in
geriatrics patients
➢ Fine or thick may
➢ Fine and straight.
look straight, curly or
kinky
➢ Distribution is fine
➢ Absence of lesion on
the scalp ➢ Distribution is not
even.
Nails
➢ Nail surface is
slightly curved or flat,
and the lateral and
posterior nail folds ➢ Nail surface is
are smooth and slightly curved, and
rounded. the lateral and
➢ Nail edges are posterior nail folds
smooth, rounded are smooth and
and clean rounded.
➢ Angle of nail base is ➢ Nail edges are
160 degrees. smooth, rounded
➢ Surface is smooth and clean
and regular, not ➢ Angle of nail base is
brittle or splitting 160 degrees.
➢ Nail plate is ➢ Surface is smooth
translucent, pink nail and regular and not
bed brittle.
 ➢ Color return is ➢ Nail plate is
instant, or at least translucent and pale.
within a few seconds

➢ Color return is
instant and at least
within a few seconds

Health History

➢ Had history of
arthritis or joint pains
➢ Experiencing back
pain
➢ Absence of bone
pain
➢ No bone deformity
➢ Needs assistance in
bathing, toileting,
dressing, grooming,
and mobility

➢ Absence of swelling
and swelling in the
joints.
➢ Absence of heat and
tenderness in the
➢ Absence of swelling
joints.
and swelling in the
➢ Presence of back
joints.
pain without
➢ Absence of heat and
tenderness.
tenderness in the
joints.
➢ Absence of muscle
pain and tenderness
➢ Absence of lesions
in the skin ➢ No redness,
muscular atrophy,
Upper Extremity deformity, or welling
is present
➢ No redness, ➢ Size and contour of
B. Muskuloskeletal muscular atrophy, the shoulders are
System deformity, or welling equal
is present ➢ The spine is slightly
➢ Size and contour of
 the shoulders are curved.
equal
➢ The spine should be
straight and the head
➢ Presence of bone
erect.
crepitation.
➢ Absence of bone
crepitation
➢ Absence of
➢ Absence of
deformity, swelling or
deformity, swelling or
redness in the elbow
redness in the elbow
➢ Elbow can be flexed
for about 70 degrees
➢ Elbow can be flexed
➢ Absence of lesions
for about 70 degrees
or swelling in the
➢ Absence of lesions
wrist and hand
or swelling in the
➢ Joint surfaces are
wrist and hand
rough with no
➢ Joint surfaces are
swelling.
smooth, with no
➢ Can extend and flex
swelling, bogginess,
the wrist with
or tenderness
limitation
➢ Can extend and flex
the wrist with no
limitation
➢ Iliac crests, gluteal
Lower Extremity folds are
symmetrical and the
➢ Iliac crests, gluteal buttocks are equally
folds are sized
symmetrical and the ➢ Can extend and flex
buttocks are equally the knees with
sized limitation
➢ Can extend and flex ➢ The skin located in
the knees the ankle and feet
are smooth with no
➢ The skin located in lesions.
the ankle and feet ➢ The joints in the
are smooth with no ankle and feet are
lesions. smooth with no
➢ The joints in the fullness, swelling or
ankle and feet are tenderness.
smooth with no ➢ Can hardly invert
fullness, swelling or and rotate his feet
tenderness. ➢ No pain with motion
➢ Can flex, evert and ➢ Pain upon bending
invert the feet the spine
➢ No pain with motion
➢ Can bend the spine
forward with no
➢ Pain upon bending
 limitation the trunk also during
➢ Can bend the trunk rotation
sideways and can
rotate it

➢ The thorax is
symmetric in an
elliptical shape
➢ Spinous process
➢ The thorax is appear curved
symmetric in an ➢ Thorax is symmetric
elliptical shape. in expansion. Lag
➢ Spinous process Absence lag in
appear straight expansion
➢ Thorax is symmetric ➢ Vibrations feel the
in expansion. Lag same in
Absence lag in corresponding area
expansion on each side of the
➢ Vibrations should chest
feel the same in ➢ Absence of
corresponding area tenderness of the
on each side of the chest wall
chest ➢ Resonance is heard
➢ Absence of upon auscultation
tenderness of the
chest wall
➢ Resonance
predominates in
 health lung during ➢ Presence of normal
percussion breath sound during
➢ Presence of normal auscultation
breath sound during ➢ Breathing should be
auscultation automatic, effortless,
➢ Breathing should be regular, even and
automatic, effortless, produces no noise
regular, even and ➢ Pattern of breathing
produces no noise is regular
➢ Pattern of breathing
is regular
C. Respiratory System