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General Appearance Cephalocaudal Physical Assessment
General Appearance Cephalocaudal Physical Assessment
The patient is conscious, well-oriented of his present condition and showed interest with the interview by
answering every question instantaneously.
The patient’s Vital Signs are normal with a temperature of 37.3 centigrade, pulse rate of 84 beats per minute,
respiration rate of 20 breaths per minute and blood pressure of 120/60.
Upon receiving the patient, the patient was pale-looking and complains of pain on both lower extremities. But
at the moment, the patient is looking good with no complaints of pain at all.
The patient has no obvious physical deformities or abnormalities.
The patient showed no sign or potential signs of distress.
Physically, the patient’s nutritional status and body built/stature is appropriate to his age.
The patient is relaxed, has an erect posture and coordinated by body movements, can freely move, flex and
extend his extremities, doesn’t use any assistive device and can voluntarily move.
The patient has a good facial expression without grimacing.
The patient’s mood is appropriate to the situation, has appropriate response, comfortable and calm.
The patient is understandable, and moderate in pace.
The patient physically looks clean and neat.
EYE
The patient’s eyebrows have evenly distributed hair, has intact skin, symmetrically aligned, and has equal movement.
The conjunctiva is transparent, capillaries sometimes evident, and sclera appears white and clear. The cornea is
transparent, shiny and smooth, details of iris are visible. The iris is brown, flat and round. The patient’s visual acuity is
normal.
EAR
The patient’s external ear canal is dry, has presence of hair follicles, no pus or blood. Normal voice tones are audible
to patient. Sound is heard on both or localized at the center of the head. Ear is without masses.
NOSE
The patient has no tenderness on sinuses. The nose is in the midline, has no discharges, no nasal flaring, both nares
are patent, and no bone and cartilage deviation noted on palpation.
CHEST (ANTERIOR)
Breathing pattern is quiet, rhythmic and effortless. Chest is symmetric upon expansion, has flat sound on the part
with heavy muscles and bony prominences, tympani on the stomach, dullness on the liver and spleen,
bronchovesicular and vesicular.
HEART
The patient’s heart has no palpable pulsation over the aortic, pulmonic, and mitral valves, no noted abnormal heaves,
and thrills felt over the apex, and no abnormal heart sounds is heard like murmurs.
UPPER EXTREMITIES
Both extremities are equal in size, have the same contour with prominences of joints, no involuntary movements, no
edema, color is even, temperature is warm and even, has equal contraction and even, can perform complete range of
motion, no crepitus noted on joints, and can counter act gravity and resistance on ROM.
ABDOMEN
The patient’s abdomen skin color is uniform, no lesions, have scar, flat, rounded, no tenderness noted, with smooth
and consistent tension, and has no muscle guarding.
LOWER EXTREMITIES
Both extremities are equal in size, have the same contour with prominences of joints, no involuntary movements, no
edema, color is even, temperature is warm and even, has equal contraction and even, can perform complete range of
motion, no crepitus noted on joints, and can counter act gravity and resistance on ROM.
MUSCULOSKELETAL
The patient’s muscles are bilaterally symmetric, has no contractures and tremors, normal muscle tension, adequate
strength of the muscle. The bones are uniform in structure, no deformities, tenderness or edema. Joints are not
tender, has smooth movement and no nodules.