PHYSICAL ASSESSMENT

I. Head

o Skull

 The head is symmetrical and normocephalic. Size varies with age and body stature.
 No tenderness noted upon palpation.
 No nodules, masses and depressions upon palpation
 Face oval, smooth, and symmetrical.

o Scalp

 The scalp is free of swelling, lesions, nodules, masses, and free from lice, nits and
dandruff.
 Lighter in color than the complexion.
 It is slightly oily.

o Hair

 The hair is in normal texture.

 Evenly distributed covers the whole scalp.
 Hair is black

 No evidence of Alopecia
 It is thick and smooth.
 Neither brittle nor dry.

II. Face
 Face oval, smooth, and symmetrical.
 No involuntary muscle movements.
 Can move facial muscles at will.
 Intact cranial nerve V and VII.

o Eyebrows
 Symmetrical and in line with each other.
 It is color black
 Evenly distributed.
III. Eyes
 The Sclera is white with no lesions or redness.
 The conjunctiva is pink.
 The pupils are equally round and reactive to light.
 Eyelids in normal position with no abnormal widening or ptosis.
 Cornea is transparent, smooth, and moist with no opacities, lens is free of opacities.
 Irises are round, flat, and evenly colored.

o Lacrimal Gland
 Lacrimal gland is non palpable.
 No tenderness on palpation.
 No regurgitation from the nasolacrimal duct.

IV. Ears
 Ears are equal in size bilaterally.
 Auricles are aligned with the corner of each eye.
 The ears skin is smooth, no lumps, lesions, nodules.
 No discharge.
 Non tender on palpation.
 The auricles have firm cartilage on palpation.
 The pinna recoils when folded.
 There is no pain or tenderness on the palpation of the auricles and mastoid process.
 The ear canal has normally some cerumen of inspection.
 No discharges or lesions noted at the ear canal.

V. Mouth & Gums

 Lips pink, smooth, and moist without lesions.
 Buccal mucosa pink, moist, and without exudates.
 32 white to yellowish teeth present.
 Gums pink without redness or swelling.
 Protrudes geographic tongue in midline with no tremors.
 Equal bilateral strength in tongue.
 Ventral surface of tongue smooth and shiny pink with small visible veins present.
 Frenulum in midline.
 Soft palate smooth and pink.
 Tonsillar pillars pink and symmetric.
 VI. Nose
 The shape of the external nose can vary greatly among individual.
 Normally, it is located symmetrically on the midline of the face that is without swelling,
bleeding, lesions, or masses.
 No discharge or flaring and uniform color.
 There is a sense of smell.
 Both nares are patent.
 No bone and cartilage deviation noted on palpation.
 No tenderness noted on palpation.
 Nasal septum in the midline and not perforated.
 The nasal mucosa is pinkish
 No tenderness noted on palpation of the paranasal sinuses

VII. Neck
 The muscles of the neck are symmetrical with the head at a central position.
 The patient is able to move head through a full range of motion without complaint of
discomfort or noticeable limitation.
 The patient may be breathing through a stoma or tracheostomy.
 Lymph nodes are not visible or inflamed.
 No visible mass or lumps.
 No jugular venous distension (suggestive of cardiac congestion).

o Trachea
 The trachea is palpable.
 It is positioned in the line and straight

VIII. Breasts
 Breast skin pale, pink with light brown areola.
 Free movement of breasts with position changes of arms and hands.
 No dimpling, retraction, lesions, or inflammation noted.
 Axillae free of rashes or inflammation.
 No masses or tenderness noted on palpation.
 The overlying the breast is even
 Not completely symmetrical at rest.
 Nipples are rounded, everted, same size and equal in color.
 No “orange peel” skin is noted which is present in edema.
  The veins may be visible but not engorge and prominent.
 No obvious mass noted.
 Not fixated and moves bilaterally when hands are abducted over the head, or is leaning
forward.
 No retractions or dimpling.
 No lumps or masses are palpable.
 No tenderness upon palpation.
 No discharges from the nipples.

IX. Thorax, Lungs, and Abdomen

 The chest wall is intact with no tenderness and masses.
 There’s a full and symmetric expansion and the thumbs separate 2-3 cm during deep
inspiration when assessing for the respiratory excursion.
 The client manifested quiet, rhythmic and effortless respirations.
 The spine is vertically aligned. The right and left shoulders and hips are of the same
height.
 There were no visible pulsations on the aortic and pulmonic areas. There is no presence
of heaves or lifts.
 The abdomen of the client has an unblemished skin and is uniform in color.
 The abdomen has a symmetric contour. There were symmetric movements caused
associated with client’s respiration.

X. Nails
 Nail beds pink without clubbing.
 Hands well-manicured with clear enamel.
 The client has a light brown nails and has the shape of convex curve. It is smooth and is
intact with the epidermis.
 When nails pressed between the fingers (Blanch Test), the nails return to usual color in
less than 4 seconds.

XI. Extremities
 The extremities are symmetrical in size and length.
 The muscles are not palpable with the absence of tremors. They are normally firm and
showed smooth, coordinated movements.
 There were no presence of bone deformities, tenderness and swelling.
 There were no swelling, tenderness and joints move smoothly.
 Have the same contour with prominences of joints.
  No involuntary movements.
 No edema
 Color is even.
 Temperature is warm and even.
 Has equal contraction and even.
 Can perform complete range of motion.
 No crepitus noted on joints.
 Can counteract gravity and resistance on ROM.

XII. Skin
 Skin pink, warm, dry and elastic. No lesions or excoriations noted.
 There are no rashes.
 There are 2 moles on his back.
 Normal skin temperature. No edema, or superficial varicosities