Physical Examination

VITAL SIGNS
Temperature
Respiration Rate
Heart Rate
Radial Pulse Rate
Blood Pressure
Oxygen Saturation
Stool
Urine
Weight
Height
BMI
 I. PHYSICAL EXAMINATION: REVIEW OF SYSTEMS
SYSTEM/AREA NORMAL FINDINGS ABNORMAL FINDINGS
GENERAL
SKIN
HEAD, EYES, Head: Head is symmetrical and of a regular shape. No deformities and tenderness
EARS, NOSE, noted. Facial movements are appropriate and symmetrical. Hair is equally distributed,
THROAT no infestation of lice.
 
Eyes: Pupils are round, reactive to light and accommodation. No history of blurring of
vision and pain. No history of use of eye drops as medications. No discharges seen.
Good eye movement and coordination. No deviations when cardinal fields are tested.
 
Ears: There are no lumps, lesions, discharges, redness, and tenderness noted. Patient
was able to hear 2 out of 3 whispered words.
 
Nose: Sense of smell intact. Nose is symmetric and centrally located. No discharges
noted. Absence of sinus pain.

Throat and Mouth: Moist mucous membranes. No ulcer, inflammation, swelling, and
redness was observed. No gum bleeding. There is no inflammation and swelling of the
tonsils noted; grade +2. Gag reflex intact.
NECK No nodules, lesions, and scars noted. No  
lumps or masses palpated. No pain in the
neck. Thyroid are palpable, it feels full but
smooth. Lymph nodes are non-palpable
BREAST  
RESPIRATORY Lungs are clear bilaterally upon auscultation.
No crackles nor wheezing heard. No use of
accessory muscles. There is no pain felt
when breathing.
 
CARDIOVASCULAR Soft, blowing systolic murmur was heard.
There is no enlargement of the jugular veins.
There is no chest pain or distress felt. Patient
is not hypertensive.
GASTOINTESTINAL Patient has no intolerance for any class of  
foods. She has good appetite and able to eat
hear meals. She has no history of diarrhea.
Stool color is clay-colored. No hemorrhoids.
ABDOMEN
GENITALS  
UTERUS  
PERIPHERAL/VASCULAR  
MUSCULOSKELETAL There is no joint swelling nor
tenderness noted. Sensation is intact
as she was able to feel the pen as it
touches her skin.
NEUROLOGIC Equal 1+ deep tendon reflexes  
bilaterally. No history of seizures and
syncope. No abnormalities of
sensation. Memory is intact.
HEMATOLOGIC No known abnormality of blood cells.
No bruises noted in any parts of the
body.
ENDOCRINE Thyroid are palpable, it feels full but  
smooth.
PSYCHIATRIC  
 III. LABORATORY AND DIAGNOSTIC TESTS
A.
DATE TEST ACTUAL VALUES NORMAL VALUES IMPLICATIONS RATIONALE
(FINDINGS)
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B.
DATE TEST RESULT RATIONALE NURSING RESPONSIBILITIES

03/15/21

 C.
DATE TEST RESULTS NORMAL VALUES IMPLICATIONS RATIONALE
03/15/21
D.
DATE TEST RESULTS IMPRESSION RATIONALE
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E.

PROCEDURE RESULTS INTERPRETATION