Date of assessment: November 23, 2009

PHYSICAL EXAMINATION

Name: Aireen Pama

Age: 30 yrs old

General survey:

Physical appearance/ grooming:

The client wake up and eat her breakfast. The patient looks restless.
There was an IV fluid of PNSS1L in her right hand. Edema and Rashes are
noticeable on her face. Her eyes were half open.

Facial Expression:
The patient looks restless.

Attitude:
The patient participates in the assessment done. she shows a positive
attitude and interest by asking me the rationale of the assessment.

Baseline Data:
8am
* Temp. : 36.5˚C
* PR : 65 bpm
* RR : 19 bpm
* CR : 68
* BP : 120/90

Head to Toe Assessment

Body Parts Technique Normal Findings Actual Findings Analysis

Skin Inspection fair complexion -Pale skin Due to decrease
in food and
Palpation nodules absent -not totally assess drinks intake.
(difficulty of
drinking and
eating)

Inspection Normocephalic (size -generally round normal

Head Palpation & shape proportional
to the body),
symmetrical in all
planes
-no tenderness
 Absence of nodules upon palpation
& masses

Hair Inspection long black straight -black,evenly Normal

hair equally distributed and
distributed covers the whole
scalp.
Thin,
Smooth, not dry
and
has no lice

Face Inspection Symmetrical, oval in -Symmetrical Normal

shape
Ears Inspection Bean-shaped, -Bean-shaped, Normal
parallel, parallel,
symmetrical, symmetrical,
proportional in size proportional in
of the head & face size of the head &
face

Hearing Inspection Able to hear voice -The patient has Normal

Acuity equally at both ears able to hear as
as evidenced by eye evidence by eye
movements towards movement a
nurse that’s
speaking. Able to
hear whisper voice.

Eyes Inspection Round and black in -Round and black Normal

color cornea. in color cornea. no
Proportional in size abnormal
of the face no involuntary
abnormal involuntary movements.-
movements.
Normal
Eye brows Inspection Present bilaterally, -Present
move symmetrically bilaterally, move
as the facial symmetrically as
expression changes, the facial
no scaling & lesions; expression
evenly distributed changes, no
scaling & lesions;
 evenly distributed

Inspection
Pupils (instrument: With normal -refuse to assess Normal
penlight, and pupillary resting size
pupillary of 4mm on right eye
measurement
attach in ruler)

Eye Inspection Has spontaneous 90 -Has spontaneous Normal

Movement degrees eye 90 degrees eye
movement movement -
Visual Acuity Inspection Able to visualize -the patient saw Normal
things as evidenced the nurse moving
by irises following closer to her.
hand movements of
nurse

Nose Inspection Midline, symmetrical -Midline, Normal

symmetrical

Mouth Inspection Proportional to the -Proportional to Normal

face, Ulcers absent, the face, Ulcers
has complete set of absent, has
teeth, dental caries complete set of
absent teeth, dental
caries absent

Lips Inspection lip margin well- - lip margin well- Normal

defined moist, defined moist,
smooth lips smooth lips

Gums Inspection Pink gums in most -redness on the Due to the

(using areas; Ulcers side of the gum. presence of
penlight) absent, pinkish in Presence of sores herpes simplex
color and blister that is
transmitted by
direct contact.

Teeth Inspection Intact teeth; Without -Intact teeth; Normal

caries, complete set, Without caries,
teeth are white in complete set,
color teeth are white in
color
Tongue Inspection Reddish & no -freely movable Normal
lesions; freely red in color.
movable

Voice Inspection Normal voice tone; -Normal voice Normal

Hoarseness absent tone; Hoarseness
absent

Neck Inspection Head position is - Head position is Normal

center to the midline, center to the
proportional to the midline,
size of the body. proportional to the
size of the body.

Palpation
No palpable lumps & -not assess
masses

Abdomen Inspection Flat -Flat Normal

No enlargement of
the liver; no -normal
distention abdominal bowel.
Auscultation

Dull sound, normal

abdominal bowel -Not assess
sounds of 15x
borborygmi sound
Percussion per minute
Not assess
Dull & soft sound
upon persussion
Palpation
Flabby, soft, non-
tender,

Upper extremities

Arms Inspection Symmetrical; size - Symmetrical; Normal

proportional w/ body; size proportional
edema absent w/ body; edema
absent

Palpation
can flex & extend Has able to stamp
ROM
freely; has full ROM her feet while
 crying.

Hands and Inspection Symmetrical; size Symmetrical; size Normal

fingers proportional w/ body; proportional w/
Cyanosis absent body; Cyanosis
absent
-warm to touch
Hands &
Palpation fingertips are
warm to touch.

Fingernails Inspection Short & clean, Short & clean, Normal

capillary refill of less capillary refill of
than 4 seconds, less than 4
absent bluish nail seconds, absent
bed. bluish nail bed.

Lower Extremities

Legs and feet Inspection Right & left leg are -Right & left leg Normal
symmetrical; size are symmetrical;
proportional to body size proportional to
size , with complete body
set of toe nails size , with complete
set of toe nails

Palpation
has good skin
turgor, warm skin, -no presence of
has no pitting edema
edema on feet,
Absence of bluish
toe nails, has no
pressure sores on
both soles of feet