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    Physical Assessment

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    Kristine Anne Soriano
    This document summarizes the results of a physical assessment of a patient. The assessment includes vital signs like respiratory rate, pulse, temperature and blood pressure which were all within normal ranges. The physical exam examined different parts of the body like the head, eyes, nose, mouth, chest, extremities and abdomen. No abnormalities were found during inspection, palpation or auscultation of each area assessed and all results were deemed normal.

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    Physical Assessment

    Uploaded by

    Kristine Anne Soriano
    56 views3 pages
    This document summarizes the results of a physical assessment of a patient. The assessment includes vital signs like respiratory rate, pulse, temperature and blood pressure which were all within normal ranges. The physical exam examined different parts of the body like the head, eyes, nose, mouth, chest, extremities and abdomen. No abnormalities were found during inspection, palpation or auscultation of each area assessed and all results were deemed normal.

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    This document summarizes the results of a physical assessment of a patient. The assessment includes vital signs like respiratory rate, pulse, temperature and blood pressure which were all within normal ranges. The physical exam examined different parts of the body like the head, eyes, nose, mouth, chest, extremities and abdomen. No abnormalities were found during inspection, palpation or auscultation of each area assessed and all results were deemed normal.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    56 views3 pages

    Physical Assessment

    Uploaded by

    Kristine Anne Soriano
    This document summarizes the results of a physical assessment of a patient. The assessment includes vital signs like respiratory rate, pulse, temperature and blood pressure which were all within normal ranges. The physical exam examined different parts of the body like the head, eyes, nose, mouth, chest, extremities and abdomen. No abnormalities were found during inspection, palpation or auscultation of each area assessed and all results were deemed normal.

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    PHYSICAL ASSESSMENT

    Assessment Vital Signs Respiratory Rate Pulse Rate Temperature Blood pressure Skin Color Turgor Lesions Rashes Bruises Texture Edema Scalp Texture Lesions Hair Color Amount and distribution Parasite Dandruff Face Symmetry Facial Anomalies Eyes Symmetry Discharge Reaction to light

    Normal Findings

    Actual Findings

    Method

    Interpretation

    14 20 cpm 70 110 bpm 36.5-37.4C Varies

    20 cpm 89 bpm 37.1C 110/60 mmHg

    Inspection Palpation Axillary temperature Auscultation

    Normal Normal Normal Normal

    Varies with race Normal turgor returns immediately No lesion present Absent Absent Smooth No edema

    Brown

    Inspection

    Normal Normal Normal Normal Normal Normal Normal

    Returns Palpation immediately (3 secs) No lesion present Absent Absent Smooth No edema Inspection Inspection Inspection Palpation Inspection

    Firm No lesion

    Firm No lesion

    Palpation Inspection

    Normal Normal

    Varies Varies with age No parasite No dandruff

    Black Equally distributed No parasite No dandruff

    Inspection Inspection Inspection inspection

    Normal Normal Normal Normal

    Symmetrical None

    Symmetrical None

    Inspection Inspection

    Normal Normal

    Symmetrical No discharge Constriction of the pupils

    Symmetrical No discharge Constriction of the pupils

    Inspection Inspection Inspection

    Normal Normal Normal

    Reaction when the light is removed Nose Symmetry Lesions and discoloration Discharge Ears Symmetry

    Dilation of eyes

    Dilation of eyes

    Inspection

    Normal

    Symmetrical No lesion. Same color as the face No discharge

    Symmetrical No lesion. Same color as the face No discharge

    Inspection Inspection Inspection

    Normal Normal Normal

    Symmetrical Pinna of the ears is aligned with the outer canthus of the eyes No discharge

    Symmetrical Pinna of the ears is aligned with the outer canthus of the eyes No discharge

    Inspection

    Normal

    Location

    Inspection

    Normal

    Discharge Mouth Texture Lesions Color Respiration Breath sounds Chest Symmetry Lesions Color Upper Extremities Symmetry Edema Lesions Mobility Lower Extremities Symmetry Edema

    Inspection

    Normal

    Smooth No lesion Pink

    Smooth No lesion Pink

    Palpation Inspection Inspection

    Normal Normal Normal

    No murmur

    No murmur

    Auscultation

    Normal

    Symmetrical No lesions Same color as the extremities

    Symmetrical No lesions Same color as the extremities

    Inspection Inspection

    Normal Normal

    Symmetrical No edema No lesions Ability to move both arms properly.

    Symmetrical No edema No lesions Able to move and control arms properly.

    Inspection Inspection Inspection Inspection

    Normal Normal Normal Normal

    Symmetrical No edema

    Symmetrical No edema

    Inspection Inspection

    Normal Normal

    Lesions Mobility Abdomen Symmetry Contour Lesions Bowel sounds

    No lesions Ability to move the legs properly.

    No lesions Able to move and control both legs properly

    Inspection Inspection

    Normal Normal

    Symmetrical Varies No lesion Occurring at least every 20 second

    Symmetrical Flat No lesion Bowel sounds present

    Inspection Inspection Inspection Auscultation

    Normal Normal Normal Normal

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