PHYSICAL 

EXAMINATION

Date of Admission: September 11, 2021 at 8:00 am

Vital Signs
BP: 220/70 mmHg
Temperature: 36 degrees celsius
PR: 140 bpm
RR: 32 cpm
Oxygen Saturation: 90%

BODY PARTS TECHNIQUE NORMAL ACTUAL FINDINGS ANALYSIS

USED FINDINGS

Skull Inspection, Proportional to the The skull is proportional Normal

Palpation size of the to
body, round with the size of the body,
prominences in the normocephalic
frontal and occipital and symmetrical to the
area, body.
symmetrical in all
place.

Scalp Inspection White, clean, free No presence of masses, Normal

from masses, lumps, lumps, scars and
scars and lesions, no lesions, and
areas of tenderness tenderness in
the area is not observed.

Face Inspection Oblong/ round/ Round, clear skin, no Normal

square or heart involuntary movement,
shaped, facial facial expression
expression that is depends on the mood or
dependent on the true feelings.
mood or true
feelings, no
involuntary muscle
movements,
symmetric facial
movements.

Eyes Inspection Sclera is pinkish as well Normal

Parallel and evenly as the conjunctiva,
spaced symmetrical, pupils slightly brown,
non-protruding, pink size is equal, rounded
palpebral and it constricts in
conjunctiva, and response to light.
pupils black in color,
 equal in size, round
and constricts in
response to light

Midline symmetrical Midline symmetrical

Nose Inspection and patent, no and patent, no discharge Normal
discharge is observed.

Parallel symmetrical, Proportional to the size Normal

Ears Inspection proportional to the of the head, cartilage is
size of the head, bean soft, clean and firm, size
shaped, skin is same is parallel and
color as the symmetrical
surrounding color,
clean and firm
cartilage.

Symmetrical, gums Not Normal

Mouth Inspection pinkish in color, lips Bluish discoloration of
margin is area around lips is Bluish (cyanotic) lips
symmetrical, no noted. may result from hypoxia.
lesion and tenderness, This is also a sign of
without involuntary respiratory distress.
movement. No dental
cavities. Lips are
smooth and moist
without lesions or
swelling.

Not Normal
Skin Inspection Varies from light to Profuse sweating and
deep brown, from cold clammy skin are Profuse sweating is an
ruddy pink to light noted. early warning sign of
pink, generally heart problems.
uniform skin
temperature. Cold, clammy skin is
Skin surfaces vary usually associated with
from moist to dry heart failure.
depending on the area
assessed.
Skin is smooth,
without lesions.
Thick, silky, resilient, Thick, black in color,
free from infestation, smooth, free from
Hair Inspection evenly distributed infestation, evenly Normal
and covers whole distributed and covers
scalp. whole scalp.
Nails Inspection, Convex curvature Bluish discoloration of Not Normal
Palpation smooth texture, nails are noted.
highly vascular and Bluish (Cyanotic) nails
pink, pink tone may indicate hypoxia. It
returns immediately is caused by a low level
to blanched nailbeds or lack of oxygen
when pressure is circulating in red blood
released. Pink tones cells. It is a sign of
should be seen. Some something serious that
longitudinal ridging requires immediate
is normal. medical attention.

Symmetrical and No masses and lumps

straight, no palpable palpated, symmetrical Normal
lumps and supple, and straight. Neck
Inspection,
Neck Region trachea is on midline supple.
palpation
of neck, and spaces
are equal on both No jugular vein
sides. distention.

Symmetrical chest The lungs were clear Not Normal

Lungs Auscultation expansion, clear to with scattered wheezes
auscultation (CTA) upon auscultation. Elevated RR of 32 cpm.
anterior and posterior Other findings are signs
(A and P), bilaterally. RR- 32 cpm of respiratory distress.
No reports of SpO2- 90%
dyspnea. Nasal The respiratory rate may
flaring and grunting be increased in response
is not observed. to pulmonary congestion
Normal respiratory or anxiety.
rate of 12-20 cpm.
Oxygen saturation of
90% is usually
associated with
hypoxemia.

Absence of heart Not normal

A dynamic murmurs (mitral &
Heart Auscultation pericardium, regular tricuspid regurgitation); Blood pressure of
rate and rhythm. No heart sounds are normal, 140/90 mmHg is already
murmur, rub, or presence of S1 and S2; considered as pre-
gallop (MRG). oxygen saturation of hypertension.
Normal heart rate is 90% are noted;
60-100 bpm May be caused by
BP- 140/90 mmHg peripheral arterial
 HR- 76 bpm vasoconstriction
resulting from an
adrenergic response to
pain, anxiety, and
ventricular dysfunction.

Inspection, General contour, no

Abdomen auscultation, discoloration in the
percussion, abdominal wall, new
palpation striae are pink or
bluish in color; old
striae are silvery,
white, linear, and
uneven stretch marks
from past
pregnancies or weight
gain, no masses, no
swishing heard, non-
distended, soft, and
non-tender.
A series of
intermittent, soft
clicks and gurgles are
heard at a rate of 5-30
per minute.
The spleen is seldom
palpable at the left
costal margin. If the
edge of the spleen
can be palpated, it
should be soft and
nontender.
Upper and Lower Inspection Equal size on both No weakness of
Extremities sides of the body, no extremities and joints, Not normal
contractures, no edema in the upper
deformities and and lower extremities. Delayed capillary refill
tenderness, normally may indicate
firm joints move Delayed capillary refill vasoconstriction,
smoothly. diminished cardiac
output, and and right
ventricular dysfunction
or failure.

Normal pubic hair Pubic hair is evenly Normal

Male Genitalia Inspection distribution, no distributed, black in
tenderness or color, no tenderness or
inflammation, no inflammation.
discharges and foul
odor.
 SYSTEM SIGNS AND SYMPTOMS

General
Fatigue
Integumentary

Skin: Profuse sweating, cold clammy skin

Nails: Bluish discoloration of nails

Mouth Bluish discoloration of area around lips

Respiratory Shortness of breathe, tachypnea, nasal flaring and

grunting, chest retractions, wheezing, persistent coughing
with pink frothy sputum

Cardiovascular Hypertension, tachycardia,