PHYSICAL ASSESSMENT

Organ/Body Parts
Skin

Normal Findings
Fair in complexion
With good skin turgor

Nails

No evidence of clubbing
of fingernails
Capillary refill: within 2-3
seconds

Head

Skull:
Hair loss

Significant Findings
Oily Skin
Cold clammy skin

Asymmetrical frontal
lobe
Hair partially distributed

Eyes
Peri-orbital area

Eyelashes

Eyelids

Conjunctiva

Pupils

Thin eyebrows, black in

color
Equally distributed,
curled slightly outward

Skin intact, (-) discharge

Shiny and smooth
Pink palpebral
conjunctiva

Cornea

PERLA
(Pupils Equal and
Reactive to Light and
Accommodation)

Sclera

Clear
(-) lesions
Appeared convex

White and buf

(-)

Ears
Auricles

Fair in complexion,
symmetrical elastic, and
mobile when pinch, and
aligned with the outer
cantus of the eyes
(+) wet cerumen

Nose
External nose

Nasal septum

Nasal cavity

Symmetrical and not

tender
Intact and in midline
Pink colored mucosa,
(+) black and white cilia

Mouth
Teeth

White in color

Tongue

Pinkish in color

Lips

Pink in color

Neck
Thyroid gland

Lymph nodes

(-) Bulging mass

Normal

(+) cheilosis

(-)
(-)
(-)
(-)
Chest
Respiratory rate

Bruits are palpated

Swelling
Enlargement
Tenderness

Normally fast

Breathing pattern Normal Breathing Pattern

Heart sounds

Abdomen
Color

normal: no murmur
(-) chest pain
(-) palpitation

Fair in complexion

Contour

Normal bowel sounds

Palpation

Palpation: soft, nontender

Musculoskeletal
Upper extremities
Pulses

Lower extremities
Legs

Radial and brachial pulse

is
normal and palpable

Long and thin legs