PHYSICAL ASSESSMENT

Patient Name: Andos, Mark Christopher

BODY PARTS TECHNIQUE NORMAL ACTUAL ANALYSIS
FINDING
FINDING
Head Palpation Rounded, Nor cephalic Patient skull is
smooth skull symmetric with of normal
contour frontal findings.
Scalp Inspection Yellowed over Flakes absent Client has no
toned, no nodules &
visible flakes masses.
Hair Inspection Evenly Hair is evenly Hair are normal
distributed distributed findings
Face Inspection Symmetric or Symmetric Normal
slightly facial findings
asymmetric movement
Eye brow Inspection Hair are Evenly Normal
distributed, skin distributed & findings
intact, eye brow skin intact
symmetrical
aligned.
Eyes Inspection
Eye lashes Inspection Equally Hair evenly Normal finding
distributed distributed and
curled slightly equal
outward movement
Eye movement Inspection
Conjunctiva Inspection Transparent Transparent in Normal
capillaries; color & smooth findings
sometimes & no lession
evident
Sclera Inspection White & White w/ Normal
vascular clear visible, findings
vascularity:
clear
Iris Inspection Flat & round Flat & round & Normal
brown in color findings
Pupils Inspection Black in color, Black in color, Normal
equal in size equal in size findings
Ear canal Inspection Dry cerumen, Dry cerumen, Normal
hair follicles no skin lession findings
visible on third
distal
Hearing Inspection Normal voices Heard & Normal
 tones audible respondent well findings
to normal voice
Nose Inspection Symmetric & Symmetric Normal
straight, no nose; no findings
discharge; discharged
uniform in
color
Lips Inspection Symmetry of Symmetric Normal
contour; contour; findings
uniform in pink pinkish color;
color; soft; dry
moist; smooth
texture
Skin Inspection Light to deep Light brown Normal
brown; Rudy over toned; skin findings
pink to light color is uniform
pink color

REQUIREMENTS
for
 DUTY
(PEDIA WARD)

Lux Mae M. Dela Cruz Mr. James Dadiro R.N

(STUDENT) (CLINICAL INSTRUCTOR)