PHYSICAL EXAMINATION

Name: Hilario, Susan M.

Age: 33 years old
Date of assessment: august 27, 2009

General survey:
1. Physical appearance/ grooming:
The patient was awake in a supine position during the assessment. She looks
restless and pale.

2. Facial Expression:
When we enter, the patient is sad. She experience pain in the suture site(facial
grimace).

3. Attitude:
The patient participates on the assessment done. She doesn’t talk about her baby
and feels discomfort upon the assessment.

Baseline Data:
0625H
* Temp. : 36.4˚C
* PR : 55
* RR : 22
* CR : 58
* BP : 110/70

HEAD-TO TOE ASSESSMENT

Body Parts Technique Normal Findings Actual Findings Remarks

skin Inspection • Symmetric • Generalized ABNORMAL

and (rounded) or pale Due to decrease
Palpation slightly • warm and dry fluid volume
asymmetric facial • poor skin and temperature
features: papebral turgor attempts to
fissure, equal in evaporate the
size, symmetric body’s water.
nasolabial folds,
free from
wrinkles.
• Sus-tanned areas
• No moist
• Pinched-up skin
returns
Head immediately
a. Skull Inspection • Smooth and soft
Palpation • generally NORMAL
round
• Generally round, • no tenderness
with prominences upon
in the frontal and palpation
occipital area.
(Normocephalic)
b. Scalp Inspection • No tenderness
Palpation upon palpation NORMAL

• Lighter in color • free from

than the dandruff, lice,
complexion and nits
• Can be moist or • no lesions,
oily tenderness,
• No scars noted masses
• Free from lice, • no scars noted
nits and dandruff
• No lesions should
c. Hair Inspection be noted NORMAL
• No tenderness nor
masses on • black, evenly
palpation distributed
and covers the
• Can be black, whole scalp
brown, or • thin
burgundy • smooth and
depending on race not dry
• Evenly • has no lice
distributed and
covers the whole
scalp (no Normal
Hearing Inspection evidences of
Acuity alopecia)
Inspection • Maybe thick or Able to respond
thin, coarse or correctly on the
smooth questions asks. NORMAL
Visual Acuity
Inspection • Neither brittle nor
dry.
Able to see the
Able to hear voice person coming near
Nose
Inspection equally at both ears as to her.
evidenced by eye NORMAL
movements towards
nurse that’s speaking. • in the midline
Able to hear whisper • no discharge
voice. • no tenderness
 upon
palpation
Able to visualize • nasal septum
things as evidenced by is in the
irises following hand midline
movements of nurse • nasal mucosa
is pinkish in
Mouth and Inspection Nose is in the midline color Abnormal
Lips • No discharges Due to fluid
• Both nares are volume deficit
patent
• Nasal septum is
in the midline
• The nasal mucosa • with visible
is pinkish to red margin
in color • slightly pink NORMAL
Tongue Inspection in color
• Symmetrical in • no edema
appearance and • cracking of
movement lips
• With visible
margin
• Pinkish in color • pinkish NORMAL
Neck Palpation • No edema • with yellow
• Moist taste buds on
the surface
• Gag reflex is • no lesions
present palpated
• Able to move the
tongue freely and • Not inflamed NORMAL
Lymph Inspection with strength straight
Nodes • with no
visible lumps
or masses NORMAL
• The neck is
Thorax Inspection straight
• No visible mass Not Palpable
or lumps
• Symmetrical
• No jugular
venous distension • Symmetrical
• chest
• May not be excursion
palpable moves
• May be normally symmetrically NORMAL
palpable in thin • normal breath
Breasts Inspection clients sounds
 • No crepitus noted
• The chest contour
is symmetrical.
• Moves
symmetrically on • darkened
breathing with no areola NORMAL
obvious masses nipples and more
• Equal thoracic darkened are
Abdomen Inspection expansion on both select.
sides

• Variable in size
depending on
body build, round
shape, • no masses
symmetrical. • no swelling,
• No lumps, atrophy or
masses, or redness
tenderness upon • stitches on the
palpation lower
• No retractions or segment due
dimpling to caesarean.
• Post op
• Skin the same in dressing NORMAL
color of abdomen
Trunk and Inspection • Contour may be
Gluteus flat, rounded, or
scapoid
Palpation • Some clients may
have striae or scar
• Skin color is
uniform • symmetrical NORMAL
• Thin clients may • same color as
Upper Inspection have visible skin
Extremities peristalsis complexion
(arms) • In extremely thin • no tenderness
clients but upon
otherwise healthy palpation ABNORMAL
individuals, it Due to poor
may be felt at blood
costal margins symmetriacal; circulation.
Lower no tenderness
Extremities inspection Skin is flesh in color has size proportion with
(legs) no lesions. body cyanosis absent

Muscle flaccidity and

pressure sore- absent
no tenderness
 symmetrical
edema on both sides
• Symmetrical of the extremities
• Equal color and
no discoloration
• No tenderness
noted on
palpation

• Symmetrical
• Equal color and
no discoloration
• No tenderness
noted on
palpation