Physical Assessment

Biographic data
Name: L.T
Data Provided by: Client
Date and Place of birth: 3/6/49; Mandurriao, Iloilo City
Age: 59
Gender: Female
Civil Status: Married
Nationality: Filipino
Religion: Roman Catholic
Significant Other: Husband, 2 daughters and 1 son
Education Level: High School graduate
Occupation: Vegetable vendor
Primary Language: Hiligaynon
Secondary Language: Tagalog, English

General Survey
The patient is sitting comfortably on chair with arms pronated on her lap. The
client speaks well and answers the question clearly and smiling without any doubts.
She answers the question accurately. During the interview I haven’t seen any problem
to the client regarding the question what I am asking for.

The patient’s vital signs are:

Temperature: 36.5°C

Pulse Rate: 76 bpm

Respiratory Rate: 16 cpm

 Blood Pressure: 120/80

A. SKIN

Fair complexion, warm and dry to touch. No evidence of vascular or purpuric

lesions. No edema.

B. HAIR

Short straight hair, clean black with few white and grey streaks, thin and dry in
texture. No scalp or lesions flaking.

C. NAILS

Fingernails are medium in length and thick. No clubbing.

D. HEAD AND NECK

Head symmetrically rounded, neck non tender, without masses. Occasionally

felt dizzy and headache.

E. EYES

Impaired vision and blurring eyes. Pinkish conjunctiva. The client uses eye
glasses.
F. EARS

Auricles and mastoid process are non tender. Bilateral auditory canals contain
the slight amount of cerumen. The client hears everything I’ve said or ask. No
hearing problem.

G. MOUTH, THROAT, NOSE AND SINUSES

Lips are moist, with no lesions. The gums are pink and moist without
inflammation, bleeding or discoloration. The tonsils are present with no
exudates or inflammation. No bleeding or swelling found in the nose. And the
sinuses are non tender.

H. HEART, NECK AND VESSELS

The client had a normal BP of 120/80 and pulse rate of 76 bpm. Occasionally
felt pain on the back of the neck.

I. ABDOMEN

The abdomen is rounded, symmetric without masses or lesions, or peristalsis

noted. Without any trail of operation or scar.
J. PERIPHERAL OR VASCULAR

ARMS: Equal in size and symmetrically bilateral. With no bruises and

scars or lesions.

LEGS: Legs are large in size and bilaterally symmetric. No bruises or

lesions, without edema and varicose.

K. MUSCULOSKELETAL

No inflammation or any bone deformities are noted. The client occasionally felt
pain on the lower limb or lumbar region.