Sacred Heart College

College of Nursing
Lucena City

PHYSICAL ASSESSMENT DOCUMENTATION

Name: __ Liam A. Mascariña _ Age: __5 years old___

Gender: _____Male______ Civil Status __Single_____

Religion: _Roman Catholic_ Nationality ______Filipino___

I. General Appearance
The face and all the physical structures of the body of the patient are symmetrical in contour
and in size. The body built and the stature of the patient is appropriate to his age. The patient
is alert and oriented to time, place, and people around him, and with keen memory of events
that had happened to him and happening around during the physical examination. The mood
of the patient is appropriate to the situation. The patient has appropriate response,
comfortable and calm during the physical examination but he is a little bit more curious to the
medical equipment used during his physical examination because of his age. He has an
average body of a 5-year-old child. He is not obese nor thin. The patient has average length of
extremities appropriate to his age. The skin tone of the patient is natural warm undertone.
There are no edemas and lesions present. There are no deformities noted. The patient is
physically clean and neat, has proper hygiene. The patient is relaxed throughout the
examination. He has collapsed posture but his body movements are well coordinated and
freely move, flex and extend his extremities without the need to use any assistive device and
the patient can voluntarily move. Since the patient is only 5-year-old, some of his words are
not understandable and he pacing when talking is moderate.

S = Face and physical structures of the body are symmetrical in shapes and in sizes.
O = Body built and stature is appropriate to his age.
M = Alert and oriented to time, place and people, with keen memory of events and happening around.
E = Mood appropriate to the situation, has appropriate response, comfortable and calm.
T = Robust body, barrel chest with physique structure of an athlete.
E = Long legged extremities, skin tone in color, no edema and deformities note.
A = Physically looks clean and neat.
M = Relaxed, with 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.
S = Words are understandable, and moderate in pace.
 II. Vital Signs T= 36.8 °C PR= 82 bpm RR=23 cpm BP= 120/80 mmhg

III. Physical Examination Findings

Skin
 The skin tone is even and without unusual or prominent discolorations.
 No presence of any foul odor.
 Skin is intact and smooth, no reddened noted.
 No presence of lesions. No obvious freckles, moles, or birthmarks. No bruises noted.
 Has no variable amount of body hair. There are also no signs of infection and
infestation as observed.
 The skin is cold to touch.
 Normal skin turgor, immediately returns to its original position when pinched.

Nails

 Nails form 160-degree angle at base; hard, smooth, and immobile.

 With Blanching test for capillary test, the nail regained a Pink appearance in less
than 2 seconds.

Head
Hair
 Hair black and shiny.
 Hair is evenly distributed.
 No infestation and infection noted.
 Hairstyle is cut around the neck.
Head
 Head is symmetrical.
 Rounded, normocephalic, erect and in midline.
 No modules, masses and deformities noted.
 Temporomandibular joint palpated with full range of motion without tenderness.

Scalp
 Smooth
 No lice or dandruff is noted
 No nodules, tenderness or lesions observed.

Eyes
Eyebrows

 Hair is evenly distributed

 Eyebrows are symmetrically aligned
 showed equal movement when asked to raise and lower.
Eyelashes

 Hairs appeared to be equally distributed

 The direction of the curl is slightly outward.

Eyelids

 No discharges observed
 No discoloration noted.
 Both lids close symmetrically with involuntary blinks approximately 10 to 15 times
per minute.

Eyeball

 Bulbar conjunctiva appeared transparent with few capillaries evident.

 Sclera appeared white.
 Palpebral conjunctiva appeared shiny, smooth and pink.
 No edema or tearing of the lacrimal gland.
 The pupils of the eyes are black and equal in size (3-7mm). PERRLA (pupils equally
round respond to light accommodation), illuminated and non-illuminated pupils
constricts.
 Pupils constrict when looking at near object and dilate at far object. Pupils converge
when object is moved towards the nose.
 Iris is flat and round.
 Cornea is transparent, smooth and shiny and the details of the iris are visible. Blinks
when the cornea was touched.
 Can see objects in periphery when looking straight ahead
 Both eyes of the client coordinately moved in unison with parallel alignment.

Ears
Auricles

 Symmetrical
 Same color with facial skin
 Aligned with the outer canthus of eye.
 Auricles are mobile, firm and not tender.
 Pinna recoils when folded.

External Ear Canal

 No impacted cerumen and odorless.

Voice Tones

 Normal voice tones are audible to patient.

  Vibrations are heard equally well in both ears. No lateralization of sounds to either ear during
Weber Test.
 Vibrations are heard longer when tuning fork is placed near ear canal than when tuning fork is
placed in the mastoid process during Rinne’s Test.

Nose
External Nose:
 Symmetric and straight
 uniform in color and is in the midline.
 No presence of discharge or flaring.
 When lightly palpated, there were no tenderness and lesions

Nasal cavity

 Mucosa is pink
 no lesions observed
 free of exudates
 nasal septum is intact and free of ulcers or perforations
 No bone and cartilage deviation.
 Both nares are patent, and able to sniff through each nostril while one nostril is
occluded. Air moves freely as the client breaths through the nares.
 No tenderness and lesions noted on palpation.

Sense of smell

 With good sense of smell. Able to identify different odor presented by the examiner.

Mouth

Lips

 are uniformly pink

 moist
 symmetric
 have a smooth texture
 no lesions and swelling observed

Teeth

 With complete sets of teeth, 32 pearly white teeth.

 One dental carry noted.

Gums

 No discoloration of the enamels

 no retraction of gums observed
  pinkish in color of gums
 firm with tight margins to the tooth
 No lesions or masses

Buccal mucosa

 appeared as uniformly pink

 moist, soft, glistening
 with elastic texture.

Tongue and floor of the mouth

 central in position
 pink
 moist
 moderate in size. The ventral surface of the tongue is smooth, shiny, pink or slightly pink
with visible veins no lesion, with whitish coating. Frenulum is midline. Tongue moves
without difficulty and without tenderness upon Palpation. \
 presence of thin whitish coating.
 Slightly rough

Hard and soft palate

 is pale or whitish
 with firm transverse wrinkle like folds.
 smooth palates are light pink and smooth while the hard palate has a more irregular texture.

Uvula
 afleshly, solid structure that hangs freely in the midline of soft palate.

Tonsils
 pink and symmetric, no exudates, swelling or lesions.
 positioned in the midline of the soft palate.

Throat
 pink without exudates or lesions

Gag Reflex is present

Neck

Neck

 symmetric
 positioned at the midline
  without tenderness, and flexes easily.
 No masses palpated with coordinated movement with the head.
 With equal muscle strength.

ROM

 Neck movement is smooth

 with good ranged of motion.

Trachea

 is located at the midline.

Thyroid

 Thyroid was not palpated.

 No bruits are auscultated.

Chest and Lungs

 Chest wall is intact with no tenderness and masses.

 Manifested quiet, rhythmic and effortless respirations.
 The spine is vertically aligned. The right and left shoulders and hips are of the same
height.
 Anteroposterior less than transverse diameter.
 Full and symmetric expansion and the thumbs separate 2-3 cm during deep
inspiration when assessing for the respiratory excursion.
 Chest expansion symmetric.
 No retracting or bulging of intercostal spaces.
 No pain or tenderness noted on palpation.
 Tactile fremitus symmetric.
 Percussion tones resonant over all lung fields.
 Diaphragmatic excursion 4 cm and equal bilaterally.
 Vesicular breath sounds auscultated over lung fields.
 No adventitious sounds present.
 Respirations 18 cpm, relaxed, effortless and quiet. They are of regular rhythm and
normal depth of rate.

Heart

 No visible pulsations on the aortic and pulmonic areas.

 There is no presence of heaves or lifts.
 Apical pulse, 82 beats/min, regular rhythm.
 No splitting of heart sounds, snaps, clicks, or murmurs noted.
 With normal hearts sounds heard upon auscultation.
 Abdomen

 Skin uniform in color, no lesions, with scar on RLQ, flat, rounded, no tenderness
noted, with smooth and consistent tension.
 Umbilicus skin tones are similar to surrounding abdominal skin tone, located midline
at lateral line inverted or protruding no more than 0.5 cm, round or conical.
 With audible bowel sound on RLQ at 8 bpm
 Generalized tympany (tympanitic) predominates over the abdomen because of the air
in the stomach.
 No tenderness, no palpable masses and no muscle guarding

Extremities

 Both extremities are equal in size, have the same contour with prominences of joints
 Muscles bilaterally symmetric, has no contractures and tremors, normal muscle
tension, adequate strength of the muscle.
 Joints are not tender, has smooth movement and no nodules.
 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.
 Negative for Babinski reflex and positive for tendon reflex.
 Has upright posture and steady gait with opposing arm swing unaided and
maintaining balance.
 Maintained stance for at least five (5) seconds.
 Can alternately supinate and pronate hands at rapid pace.
 Able to discriminate between sharp and dull sensation when touched with needle and
cotton.

Recorded by:

____________________________ Documentation time (15 mins.) _____

Student’s Name Start: ________
End: _________
Checked by:

____________________________
Clinical Instructor