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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
Not examined Not examined
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
Not examined Not examined
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
Not examined Not examined
Auscultation of the
trachea
Auscultation Bronchial and tubular breath
sounds
Breath sounds are clear Normal
Auscultate the anterior
thorax
Auscultation Bronchial and vesicular breath
sounds
Breath sounds are clear Normal
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
Not examined Not examined
Percuss abdominal
quadrants
Percussion Tympany over the stomach
and gas-filled bowels;
dullness, especially over the
liver and spleen, or a full
bladder
Not examined Not examined
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