PHYSICAL ASSESMENT

I.
GENERAL APPEARANCE
a. Body Build
: Medium Frame
b. Height and weight
: 5¶7´; 122 lbs
c. Posture
: erect and straight body posture
d. Hygiene and grooming
: clean and neat
e. Body breath and odor
: none
f. Appearance
: appears weak
g. Mental status
: clear and intact memory both recent and remote, oriented to person, time and
place
h. Attitude
: cooperative
i. Mood and affect
: appropriate to situation
j. Organization of speech
: understandable, moderate pace
k. Relevance and organization:
has logical sequence and sense of reality of thought
II.
VITAL SIGNS
a. Temperature
: 36.6¶ C
b. Pulse Rate
: 75 bpm
c. Respiration Rate
: 18 bpm
d. Blood Pressure
: 110/70 mmHg
III.
INTEGUMENT
A. Skin
a. Color complexion
: fair complexion
b. Skin moisture
: dry, slightly wrinkled, dry lips
c. Skin temperature
: normal
d. Skin turgor
: slightly poor skin turgor

B. Nails
a. Fingernail plate shape : convex
b. Texture
: smooth
c. Bed color
: pink
 d. Capillary refill
: pink in color returns after 5 secs.
- Intact epidermis around the nail
IV.
HEAD
A. Hair
a. Color
: black
b. Distribution
: evenly distributed
c. Texture and oiliness
: silky, fine and oily
- Thin strands of hair

B. Scalp

- Absence of drandruff

- No lesions, masses, deformities, swelling and tenderness.

C. Skull

- Normocephalic

- Smooth, uniform consistency; absence of nodules or masses

D. Face - symmetrical facial features and movements

E. Eyes and Vision
a. Eyebrows
: eyebrows are black, evenly distributed and
symmetrically aligned
b. Eyelashes
: equally distributed, slightly curled outward
c. Eyelids
: skin is intact, lids close symmetrically
d. Bulbar conjunctiva : transparent, capillaries are not evident,
sclera appears yellowish
e. Palpebral conjunctiva: shiny, smooth, and slightly yellowish
f. Lacrimal gland
: no edema, or tenderness over the gland
g. Pupils
: black in color, iris appears yellowish
h. Visual acuity
: decreased visual acuity, difficulty in reading
prints in near vision (farsighted 65 degree)
i. Visual field
: decreased peripheral vision
ual reaction to light and accommodation: normal

constriction of pupil upon the presence of light (

PERRLA)

F. Ears and hearing

a. Auricles

: symmetrical, skin color is same with facial

skin, aligned with outer canthus of the eye;

movable, firm and tender, recoils back after it is

folded

b.
External ear canal : with scant amount of
cerumen and few cilia
c. Gross hearing acuity test: able to hear normal voice and able to
hear whisper voice within 6 inches (15. 24 cm)
V.
NECK
: No area of tenderness
-No masses found
-Range of motion is done actively within normal limits
and pain free
VI.
CHEST

t a. anterior chest : intact skin with uniform color,

-no area of tenderness,

-no mass is found with visible bone prominence

-Symmetrical chest expansion

b. Posterior Chest : fair complexion

- smooth skin

- no evidence of enlargement

- no area of tenderness

- no mass is found
UPPER EXTREMITIES

a. Shoulder
: range of motion on right shoulder is actively done
within normal limits and pain free.
- Left shoulder¶s range of motion are done in active
assistive with restricted motions due to IV line
b. Elbows
: range of motion on left elbow is actively done within
normal limits and pain free.
-Right elbow¶s range of motion is done actively with
normal limits and pain free.
c. Wrist and hands : range of motion of right wrist and fingers are
actively done within normal limit and pain free.
- Left wrist and fingers are not movable due to
inserted IV line.
d. Muscles
: No tenderness found
VIII. ABDOMEN
: soft abdomen, no masses and areas of
tenderness
-Uniform
in
color
with
no
evidence
of
enlargement of liver and spleen.

-Umbilicus is in the normal position between the xiphoid process and symphysis pubis with

Normal Abdomen Bowel Sound (NABS)

IX. LOWER EXTREMITIES : fair complexion, smooth skin, symmetrical\muscles,

intact skin, warm to touch with good muscle tone
-Range of motion on joints is done within normal limits and
pain free.

-Toe nails: with good capillary refill upon blanch tests (<5 secs), convex, pinkish nail beds with intact

skin around the nails.