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Physical Assessment

General conscious, coherent, Vital signs - BP- 110/40mmhg PR-98bpm RR-25 Body Part Techniqu Normal Findings e used Skin Inspectio Uniform in color, no abrasions or n any lesions Well moistened skin.
Skull & Face

Temp-36.5 Actual Findings Uniform in color, dry and rough skin with wrinkles and age spots due to aging Round or normocephalic; No any presence of masses or nodules; symmetrical facial movements Evenly distributed. No presence of pediculosis. Evenly distributed and eyebrows symmetrically aligned Lids closes symmetrically; Skinny smooth, yellowish conjunctiva; no edema or tenderness. Equally distributed Closed symmetrically, Skin intact, no discharge, no discoloration.

Analysis Abnormal findings

Inspectio n Palpation

Round or normocephalic; smooth, absence of nodules or masses; symmetric facial movements.

No abnormal findings

Hair Eyebrow

Inspectio n Inspectio n

Even distribution of hair. Resilient think hair with no signs of infections or infestations Even distributed hair, Eyebrows symmetrically aligned; Lids close symmetrically; Skinny smooth, pinkish conjunctiva; no edema or tenderness. Equally distributed, curled slightly outward Skin intact, no discharge, no discoloration, lids closed symmetrically.

No abnormal findings

No abnormal findings Abnormal findings

Eyes Inspectio n Eyelashes Eyelids Inspectio n Inspectio n

No abnormal findings No abnormal findings

Pupils(color, shape,

No abnormal findings

symmetry of size) Ear Inspectio n Inspectio n

Black in color, equal in size, normally 3-7ml in diameter, round smooth boarder, iris flat and round. Color same as facial skin Symmetrical; mobile, firm and not tender; no notable discharges. Normal voice tones audible

Equally in size No presence of lesions and discharges. Normal voice tones audible. No abnormal findings

Nose and Sinuses

Inspectio n

Symmetric and straight; No discharge or flaring: not tender, no lesions. Uniform in color Air moves freely as the patient breaths through the nares. No tenderness in maxillary and frontal sinuses

Symmetrical and straight; Without any presence of discharges and lesions. Breaths freely. No tenderness in maxillary and frontal sinuses Symmetrical lips; slightly dry lips Normal in position but with whitish in color.

No abnormal findings

Mouth Tongue

Inspectio n Inspectio n

Uniform in pink color; Symmetrical lips In central position; pink in color Moves freely with no tenderness Smooth tongue base with prominent veins, smooth with no palpable nodules.

Abnormal findings Abnormal findings

Teeth

No dentures

No abnormal findings

Inspectio n Neck muscles Lymph nodes Upper extremities Palpation Inspectio n Palpation Inspectio n Palpation

32 adult teeth, smooth, white, shiny tooth enamel No retraction of gums Coordinated, smooth movement with no discomfort. Not palpable Muscle; equal size on both sides of the body. No contractures Bones; no skeletal deformities. Joints; no swelling, tenderness, crepitation or nodules. Moves freely Posterior thorax: Symmetrical; spine vertically aligned; Hips are the same in height. Skin intact; uniform temperature. No tenderness and no presence of masses Vesicular and bronchovesicular breath sounds Anterior thorax: Quite, rhythmic, and effortless respirations; No tenderness and no presence of masses Coordinated movement without any discomfort No palpable mass No contractures and deformities. Moves freely. No abnormal findings No abnormal findings

Thorax and lungs

Inspectio n Palpation Percussio n Auscultati on

Normally aligned; skin intact and no presence of masses. Accelerated breathing with productive cough.

Abnormal findings

Abdomen

Inspectio

Unblemished skin; Uniform in

Presence of age spots

Abnormal findings

n Auscultati on Percussio n Palpation Lower Back Lower Extremities Inspectio n Palpation Inspectio n Palpation

color Flat, rounded or scaphoid Symmetric movement caused by respiration Audible bowel sound Unblemished skin Uniform in color Symmetry Muscle: Equal in size on both sides of the body No contractures. No lesions, swelling and inflammation Bones: No skeletal Deformities. Joints: no swelling, tenderness, crepitating or nodules and moves freely.

due to aging; flat, audible bowel sound; right lower quadrant pain

Symmetrical with age spots due to aging Equally aligned, no contractures or deformities. Moves freely.

No abnormal findings No abnormal findings

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