PHYSICAL ASSSESMENT

Vital Signs:

BP:160/100      

T: 35.9 

P: 87   

R: 15   

Body Parts	Normal Findings	Abnormal Findings
Hair And Scalp	Evenly distributed thick, silky, resilient hair. No infection or infestation.
Face and Skull	Rounded, smooth skull contour, absence of nodules or masses, symmetric or slightly asymmetric facial features, symmetric facial movements
Skin	From light to deep brown Uniform in color No edema lesions noted, no pigmentation Brings back to previous state after pinching Normal temperature @ 37C
Eyes	Symmetrically aligned with equal movements	Slightly yellowish sclera
Ears	Symmetrical in shape and aligned in the outer canthus of the eye No tenderness, recoils after it is foiled No discharge
Nose	No discharge, no lesion and tenderness, no obstruction
Lips	No blister/cracks, moist
Tooth and gums	Pink gums, not swollen Smooth and white shiny enamel	Dark gums Yellowish teeth
Tongue	Centered, no lesions, smooth movement
Neck	Equal in size, head centered with muscles ( trapezius and sternocleidomastoid) equal in size No unusual mass noted upon palpation No enlargement of lymph nodes No distention of veins, No enlargement of thyroid gland
Thorax and Lungs	Spine is vertically aligned, no tenderness, pain, or unsual mass upon palpation Tactile fremitus present Clear breath sounds
Heart	Has a regular rate and rhythm
Abdomen	Unblemished skin Uniform in color, no swelling or lump noted Tympanic sound heard upon auscultation Symmetric contour Symmetric movements caused by respirations No tenderness
Extremities	No edema, deformities, tenderness noted Have symmetrical lower and upper extremities Clean fingernails and toenails Blanch test ( color return < 3 seconds )	Dirty fingernails