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PHYSICAL EXAMINATION

(Pre-physical exam)
1. General information  Both nares patent
Name: Dela paz, Demetrio  Pinkish mucosa
Age: 58 y/o  Tender sinuses
Sex: Male
Civil Status: Single 9. Mouth
Home address: 3821 PHAO, Pasig city  No dentures
 No teeth
2. Vital Signs  (-) lesions
BP: 110/70
 Tongue in midline
Temp: 38.1
 Gums pinkish
RR: 32
PR: 96  Uvula in midline
Wgt: 64.3 kg.  Tonsils not inflamed
Ht: 5”4  Moist buccal mucosa

3. General Survey 10. Neck


 Conscious  Trachea in midline
 Coherent  Non-palpable cervical lymph nodes
 Oriented to time and place  Non-palpable thyroids
 Looks acc. to age  (-) neck enlargement
 Normal ROM
4. Skin
 (-) pallor 11. Breast and Axillae
 Skin dryness  Equal size, symmetrical
 Cracking lips  (-) discharge, nipple masses
 Warm skin temperature  (-) edema, tenderness

5. Head 12. Chest and Lungs


 Normocephalic, symmetrical  AP ratio 1:2
 Fine hair, normal hair distribution  Symmetrical chest expansion
 (-) alopecia  (-) wheezes, rales, rhonci
 (-) dullness
6. Eyes  (-) retraction
 Lids symmetrical
 Smooth clear eye lenses 13. Abdomen
 Equal pupil size  (-) scars
 L,R pupil briskly reactive to light  (-) Murphy’s sign
 Uniform constriction  (-) fluid wave
 Normal visual acuity  (-) tenderness
 Hyperactive bowel sounds
7. Ears  Gallbladder not palpable
 Pinnae symmetrical
 (-) foul smell, serous, purulent, 14. Back and extremities
mucoid, impacted cerumen  Peripheral pulse symmetrical, regular
 Hearing Problem  Pale nail beds
 (-) edema
8. Nose  (-) delayed capillary refill
 Symmetrical  (+) non healing wound (R foot)
 Septum in midline (-) perforation  (+) weakness

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