╬PHYSICAL EXAMINATION╬

►General Physical Survey

A. Appearance & Behavior

1. Age, Sex, and Race: 60 y/o, Female, Asian
2. Body Build: Proportionate to age, a height of 5’2,
slightly
Immobilized movement, thin,
3. Posture & Gait: Straight & erect, walks with balance and
Coordination but needs assistance.

4. Hygiene & Grooming: Wears slightly clean and neat shirt & pants,
No
Foul body odor, unfixed hair with nails
improperly trimmed.
5. Dress: Dressed appropriately to age, sex, place,
Religion & climate, wears sleeve
purple in color with smooth checkered
pants overlap with “malong” dark in
color.
6. Odor of body & Breath: (-) body odor, (-) halitosis
7. Signs of distress: Mild facial grimaced, Displaying marked
changes
In personality.
8. Apparent state of health: Physically unfit due to disease
condition.
9. Attitude: Cooperative & participative with procedures
&
Treatment rendered.
10. Affect/Mood: Responds appropriately on topic discussed &
Expresses feeling appropriate on
situation
11. Speech: Slightly unclear, loud, comprehensive,
Vagueness with her stories.
12. Thought Process: Well oriented to time, place and situation,
Expresses full and slightly
unorganized thoughts sometimes she
tend to forget what happened in the
past when we ask & needs to be
reminded by her watcher

B. Vital Signs
Temperature: 37.1 ˚C
Respiration: 26 b/m
Pulse: 70b/m
Cardiac Rate: 75 b/m
Blood Pressure: 150/100 mmHg

C. Height & Weight:

Height: 5’2
Weight: 50 kg

►Integumentary

The skin is dryer, tan in color, thinner and less elastic with fewer
sweat and oil glands to moisten and protect it. It tears and bruises
more easily. The hair is slightly long hair just about at axillary
level and is evenly distributed, black in color with few white hairs
due to aging , no lesions noted upon palpation. The nails are
smooth, firm and pink, nail round & hard, bound nail with 160˚ nail
base.
 ►Head

The skull is about 57 cm, symmetrically; no deformities and

tenderness noted, diamond shaped of the face and tan in color,
with mildly moist skin on the face
No scales, lumps and lesions noted upon palpation the scalp.

►Eyes and Vision

A. External Eye Structures:

The hair distribution of the eyebrows is in its entire length, and

symmetrically The lashes are curled outwards, evenly spaced, and
the edges of the lids are in apposition to eye balls; upper margins
of lid cover approximately 2 mm of iris, when the patient is
looking straight; approximately 15 involuntary blinks per min; no
lesions noted, the bulbar conjunctiva is smooth & clear, no lesions
noted, the palpebral appears pink, no lesions & discharges noted

B. Lacrimal Apparatus

Small lacrimal gland is recognized , Absence of edema noted in

the lacrimal sac, no evidence of decrease/increase in tearing.

C. Iris: Brown in color, flat, and round

D. Pupil: Both pupils constrict consensually size is 3mm in

diameter

1. Visual Acuity: Able to read newspaper approximately font size of 16-20

at a
distance of 12 inches
2. Peripheral: Can see object/person in the periphery when looking
straight
ahead.

►Ears

In external ear the cartilage is firm in texture & movable,

symmetrically align, equal in size. Upon inspecting the ear canal,
absence of swelling or redness, nodules, discharges and foreign
bodies noted, the patient was able to hear the student nurse’s fingers
rubbed lightly together 3-4 inches from his ear

►Nose

Septum is in the middle and turbinate’s project into the nasal

passages, The air flows through nares, able to recognize scent, No
tenderness noted on the sinuses upon palpation.

►Mouth

Upon inspecting the lips it appears pinkish in color, dry, no lesions

noted, moist is noted upon assessing the buccal mucosa, no
ulcerations noted, the gums appears absence of lesions, not
 inflamed, no swelling & bleeding, the teeth is Incomplete, absence of
natural teeth from up and down, she wears dentures, with slight oral
distinct odor, the tongue appears to be rough, frenulum centered,
with no lesions noted with symmetrical uvula at midline; edema and
ulceration abse

►Neck

The thyroid gland appears centered head position, symmetrical,

smooth, firm, with no tenderness, with lymph nodes mobile, size and
shape equally distributed, jugular veins not visible

►Upper Extremities

Both arms can stretch, flex, slowly rotate and extend without
difficulty. No signs of
lesion and bruises noted. Fingernails are improperly trimmed and with
traces of dirt noted.

►Lower Extremities

Both legs can stretch, flex, rotate, extend and bend slowly. She needs
assistance in walking. Toenails are untrimmed and with traces of dirt
noted. No signs of deformities, lesions, lacerations, and bruises.

►FOCUS ASSESSMENT

►Chest

1. Inspection
a. Rate, rhythm, depth, and effort of breathing :
→ 36breaths per minute with discomfort, periodic deep breathing
more than 5 per minute, irregular rhythm
b. Shape of chest and symmetry of chest expansion:
→symmetrical expansion,
c. Use of accessory muscles and retractions of intercostals muscles:
→accessory muscle positively used
d. Presence of productive cough and sputum:
→negative productive cough, sputum clear without odor
e. Position of comfort:
→Moderate High Back Rest, Sidelying

2. Palpation
a. Tenderness around lesion:
→No lesions noted on chest

3. Ausculation
a. Presence and loudness of breath sounds throughout lung fields:
→Bronchial breaths sound heard over lung as client takes low,
deep breaths through the mouth while the examiner auscultate for
two full breaths.
b. Breath Sounds
b.1 Bronchial: Inspiration is greater than expiration, heard over
lung periphery
b.2 Vesicular: Breath sound is decrease unlike auscultating
bronchial
b.3 Ausculate for altered voice sounds over lung periphery:
 b.3.1 Bronchophony: Sounds loud and clear as the client
says “99”
b.3.2 Whisphered: Sound muffled as the client says “one,
two, three”
while the examiner auscultates.
b.3.3 Egophony: sound like muffle “ee” as the client says
“ee” while the
examiner auscultates.

►Heart

1. Inspection and Palpation

a. Point of maximal impulse: PMI displaced laterally about 2 inches
from the
midclavicular line
c. Pulsation over chest wall: Pulsation noted over the tricuspid area

2. Ausculation:
a. First and second heart sound at aortic, pulmonic, mitral, tricuspid
areas:
●Heart rate and rhythm:65 bpm, irregular rhythm
●Apical and radial pulse: CR: 65 bpm
PR: 60 bpm

3. Extra sounds and murmurs:

→High-pitched “blowing” holosystolic murmur noted on the fourth left
sterna border with patient in lateral decubitis position; low intensity, high-
pitched diastolic murmur heard over right second intercostals space,
especially if the patient leans forward and holds breath in full expiration.