PHYSICAL ASSESSMENT

Physical examination follows a methodical head to toe format in the

cephalocaudal assessment. This is done systematically using the techniques of
inspection, palpitation, percussion and auscultation with the use of materials and
investments such as the penlight, thermometer, sphygmomanometer, tape measure and
stethoscope and also the senses. During the procedure, we made every effort to
recognize and respect the patient’s feelings as well as to provide comfort measures and
follow appropriate safety precautions

General Survey

Patient name: Daniles,Milagros Tan. Age: 77 yo. Bday: 04/13/1942

Weight: 63.1 kg Height: 5’3

VITAL SIGNS:

BP: 140/90 mmHg PR: 81 bpm RR: 20 cpm T: 36.4 C

SYSTEM/ NORMAL ACTUAL INTERPRETATION

FINDINGS FINDINGS
METHOD OF
ASSESSMENT
Normal, since there
were no abnormalities
SENSORY AND Level of Level of
noted upon
NEUROLOGICAL consciousness consciousness assessment.
SYSTEM The patient is The patient is
(Interview and oriented to time, oriented to time,
demonstration) people, and place. people, and place.
Enable to demonstrate Enable to demonstrate
emotion appropriate emotion appropriate
to the scenario. to the scenario.
Enable to Enable to
comprehend and comprehend and
speak fluently. speak fluently.
Visual recognition Visual recognition
The patient able to The patient able to
identify familiar identify familiar
objects by sight objects by sight
(pencil & ballpen). (pencil & ballpen).

Light touch Light touch

Brush a light stimulus The patient identifies
using cotton wisp areas stimulated by
over patient’s skin in light touch
several locations,
including extremities.
Patient must
identify the areas
stimulated by light
touch

Pain
Stimulate skin lightly Pain
with sharp and dull The patient identifies
ends of hairpin. areas stimulated
Apply stimuli (right forearm) and
randomly and ask type of stimulation
patient to identify (dull part of hair pin).
whether sensation is
sharp or dull. The
patient must identify
 areas stimulated and
type of stimulation.

Graphesthesia Graphesthesia
With patient’s eyes Patient able to
closed, use index identify the numbers
finger to trace a on her left (8) and
number on patient’s right (3) hand.
hand, and ask patient Graphesthesia is
to identify the intact bilaterally.
number.
Graphesthesia must
be intact bilaterally.

Point localization Point localization

Patient must have the Patient able to locate
ability to sense and areas (right arm and
locate area being left knee) being
stimulated. With eyes stimulated. Point
closed, touch the area localization intact.
then have the patient
point to where she
was touched. Test
both upper and lower
extremities.
Point localization
must be intact.

The client skin is The client skin is Normal, since saggy

INTEGUMENTARY
uniform in color. uniform in color skin and rough are
SYSTEM
Soft, smooth skin (fair white). indicated to those old
 SKIN over the entire body. Slightlrough skin aged.
(Inspection and Edema is normal in over entire body.
palpation) pregnancy, skin Saggy skin on both
temperature is within lower extremities
normal limit. noted. Skin
temperature is within
normal range upon
assessment.

HEAD Head is The patient’s head is Normal, since the

(Inspection and normocephalic, with round and head is
palpation) prominences in the symmetrical. No normocephalic and no
frontal and occipital tenderness upon tenderness, lesion and
area. inspection. nodules, white hair is
No tenderness noted No tenderness noted indicated to those old
upon palpation.
upon palpation. aged.
Symmetrical, no
Symmetrical, no lesions, nodules or
masses. Free from
lesions, nodules or
lice, nits and
masses. Free from dandruff. Hair is
thick medium in
lice, nits and
length and slightly
dandruff. May be thin dry. White hair are
noted upon inspection
or thick hair. Neither
brittle or dry.
Chloasma may be
FACE Presence of triggered by hormonal
Symmetrical, no
(Inspection) Chloasma noted upon changes during old
lesions, nodules or
inspection. No aged, which stimulate
masses. Presence of
lesions, nodules or a temporary increase
chloasma is normal in
masses noted. in the amount of
 pregnancy melanin the body
produces.

The patient’s neck is Normal, since there

The neck is straight. were no abnormalities
NECK straight. No visible
No visible mass or noted upon
(Inspection) mass or lumps. assessment.
lumps. Symmetrical.
No jugular venous Symmetrical. No

distention. jugular venous

distention.

VISUAL SYSTEM Evenly placed and in The eyes of the Abnormal, Upon
line with each other. patient were in line testing for visual
acuity the patient is
EYES None protruding. with each other. Not refuse while she cant
Equal palpebral protruding. Equal even read the news
(Inspection) paper without the eye
fissure. palpebral fissure glassess. and as per
noted. patients info she has a
past diagnosed to her
eyes but she cant
remember what is it.
 Testing Visual Acuity The patient is having
Have patient hold a difficulty to read
newspaper about 14 the news paper
inches away and read.

Corneal LightReflex Light is seen

Test symmetrically on
patient’s each cornea.
Shine light directly in
patient’s eyes; note
position of the light
reflection off the
cornea in each eye.
Light should be seen
symmetrically on
each cornea.
GASTRO-
Patient lips was
INTESTINAL
The lips are normally
slightly pink and dry.
SYSTEM
symmetrical, pink,
Yellowish in color
Not normal, since
smooth, and moist.
with complete upper
MOUTH client teeth has some
Teeth should be clean
dental carries she has
(Inspection) dental carries.
with shiny enamel
4 left and decaying
It is advisable for old
and no decay, white
teeth in lower area .
aged to have dental
with shiny enamel
Oral mucosa was
check up and increase
and smooth surfaces
smooth, shiny and
her daily amount of
and edges.
pinkish. Tongue move
calcium during old
Oral mucosa should
freely and symmetric,
age Sufficient
appear moist, smooth,
pinkish, slightly
calcium will protect
shiny and pink.
rough from the
her bone mass and
A healthy dorsal
papillae.
tongue is teeth.
symmetrical, pink and
moist and slightly
rough from papillae.

ABDOMEN
Unblemished skin.
(Auscultation, Uniform in color. Normal,since
Inspection and saggy, rounded, or No White stretchmarks is stretchmarks are
Palpation) evidence of related from her
noted.. Liver and
enlargement of liver pregnancy before.
and spleen. spleen not enlarged
Symmetric contour.
upon assessment.
Symmetric movement
caused by respiration. Symmetric movement
Audible bowel
caused by respiration.
sounds. No
tenderness; relaxed Audible bowel sound.
abdomen with
Using doppler, No
smooth, consistent
tension. Bladder not tenderness noted.
palpable.
Liver and bladder not
palpable.

No pulsation upon
The patient’s heart
CARDIO- palpating the aortic Abnoormal, since the
rate was 80bpm and
and pulmonic areas. patient’s BP falls
VASCULAR BP of 140/90. No
No lift or heaves. within abnormal
pulsation upon
SYSTEM Heart rate ranges range upon
assessment the aortic
from 60-100bpm and assessment.
and pulmonic area.
systolic BP of <120
HEART and diastolic BP of
<80
(Auscultation)
Abnormal, since
Upon ausculktation
Chest wall intact; no crackles are
RESPIRATORY the patients lung
tenderness; no associated with the
sound having a
SYSTEM masses. Full and pneumonia
crackles.
symmetric chest
expansion. Clear
LUNGS vesicular adnd
bronchovesicular
(Auscultation)
breath sounds. Quite,
rhythmic, and
effortless
respirations.

Normal since the

Patients verbalized
No pain or burning patient doesnt feel
that there is no pain
sensation while discomfort when
GENITO- when urinating and
urinating. Normal urinating and the
the urine color is
URINARY urine color ranges yellow color is with
yellow
from pale yellow to in normal..
SYSTEM
deep amber.
(Interview)