PHYSICAL ASSESSMENT

Patient: X

General survey:

July 4, 2020 Saturday morning, the patient was received at 10 am. She is
lying on bed and awake, the patient is conscious and coherent.

Vital signs:

Body temperature: 38.4

Respiratory Rate: 16 breaths per minute

Pulse rate: 75 beats per minute

Body Parts Method used Findings Interpretation

Skin  Inspection  Light  Normal
 Skin turgor brown in
 Palpation color  Normal
 The skin
goes back
to its
normal
state after
pinching

 Absence of  Pallor;
underlying indicates
red tones anemia,
illness,
emotional
shock/stress

Hair  Inspection  Evenly  Normal

distributed
hair
Head  Inspection  Scalp is  Normal
  Palpation shiny,
intact,
without
lesions or

masses
 systematic
facial
features
and
movement
Eyes  Inspection  Uneven  Astigmatism
curvature
of the
cornea
that
prevents
horizontal
and
vertical
rays from
focusing on
the retina
 Distorted,
wavy
mirror
 Blurred
vision at all
distances
.
Ears  Inspection  No  Normal
infection
and has no
signs of
bleeding
Nose  Inspection  Symmetric  Normal
and
 straight
 No signs of
nose
bleeding
 No
tenderness
or lesions
 Uniformity
in color
 No
discharge
or flaring.
Mouth  Inspection  No  Normal
tenderness
when
palpating
for the soft
and hard
palate
using
tongue
depressor

 Lips  Inspection  Pinkish and  Normal

smooth
 Symmetric
al curve
 Teeth  Inspection  Inflammati  Due to
and on of the gingivitis
gums gingiva

 Tongue  Inspection  Tongue is  Normal

normal;
has no
signs of
inflammati
on.
Neck  Inspection  The neck is  Normal
 Palpation normal and
has no
swelling,
enlarge
mass or
nodules.
 Full ROM,
pain free,
symmetric
al muscles.
Chest  Inspection  No  Normal
 Palpation retraction
 Auscultatio when
n breathing;
no use of
accessory
muscle  Normal
 Symmetric
chest  Normal
movement
 No
presence
of crackle
Abdomen  Inspection  No  Normal
 Palpation enlargeme
nt and
tenderness
Upper extremities

 Inspection  Normal;  Normal

has no
signs of
inflammati
ons and
tenderness
Lower  Inspection  Symmetrical  Normal
extremities  Palpation both left and
right
 Legs  Leg pain  Due to
stress and
poor
circulation
of blood
 Feet  Inspection  Appearance of  Corns
 Palpation patches of
thickened skin