PHYSICAL ASSESSMENT

DATE ASSESSED April 01, 2019 @ 10:00 am

INITIAL VITAL SIGNS Blood pressure 100/60 mmHg
Temperature 36.9 °C
Pulse rate 119 bpm
Respiratory rate 20 cpm
GENERAL APPEARANCE The patient was assessed sitting on the bed. Patient was
hooked to PNSS 1L X KVO with PNSS 96 cc + 1 ampule
Levophed X 20 ugtts and PNSS 100 cc + KCl 10 meq as side
drips to run for 1 hr. The patient was lethargic and had pale
lips. At 12:30 in the afternoon patient had blood transfusion
(PRBC B+) 280 cc infused for 4 hours.

DATE ASSESSED April 02, 2019 @ 08:00 am

INITIAL VITAL SIGNS Blood pressure 90/60 mmHg
Temperature 37 °C
Pulse rate 120 bpm
Respiratory rate 22 cpm
GENERAL APPEARANCE The patient was assessed sitting on the bed. Patient was
hooked to PNSS 1L X KVO with PNSS 96 cc + 1 ampule
Levophed X 20 ugtts. The patient was lethargic and had pale
lips.

DATE ASSESSED April 03, 2019 @ 08:00 am

INITIAL VITAL SIGNS Blood pressure 90/60 mmHg
Temperature 36.7 °C
Pulse rate 115 bpm
Respiratory rate 20 cpm
GENERAL APPEARANCE The patient was assessed sitting on the bed. Patient was
hooked to PNSS 1L X KVO with PNSS 96 cc + 1 ampule
Levophed X 20 ugtts. The patient was lethargic and had pale
lips.

DATE ASSESSED March 25, 2019 @ 10:00 am

INITIAL VITAL SIGNS Blood pressure 80/50 mmHg
Temperature 37.1 °C
Pulse rate 101 bpm
Respiratory rate 21 cpm
GENERAL APPEARANCE The patient was assessed sitting on the bed. Patient was
hooked to PNSS 1L X 42 gtts. PNSS 96 cc + 1 ampule Levophed
X 35 ugtts and PNSS 100 cc + KCl 10 meq as side drips to run
for 1 hr. The patient seems weak and pale. 2 units of PRBC was
ordered to be transfused for 2 hours.
 DATE ASSESSED March 26, 2019 @ 8:00 am
INITIAL VITAL SIGNS Blood pressure 90/60 mmHg
Temperature 37.7 °C
Pulse rate 120 bpm
Respiratory rate 21 cpm
GENERAL APPEARANCE Received patient was sitting on the bed. Patient was hooked
to PNSS 1L X 42 gtts. PNSS 96 cc + 1 ampule Levophed X 30
ugtts and PNSS 100 cc + KCl 10 meq as side drips to run for 1
hr. The patient seems weak and pale. Albumin 20% was given
+ furosemide once done with BP precaution. Patient was also
given total parenteral nutrition of Combiflex 1,400 kcal to run
for 24 hours.

DATE ASSESSED March 27, 2019 @ 8:00 am

INITIAL VITAL SIGNS Blood pressure 80/50 mmHg
Temperature 37.7 °C
Pulse rate 118 bpm
Respiratory rate 21 cpm
GENERAL APPEARANCE Received patient was sitting on the bed. Patient was hooked
to PNSS 1L X 42 gtts. PNSS 96 cc + 1 ampule Levophed X 25
ugtts and PNSS 100 cc + KCl 10 meq as side drips to run for 1
hr. The patient seems weak and pale. Albumin 20% was given
+ furosemide once done with BP precaution. Patient was also
given total parenteral nutrition of Combiflex 1,400 kcal to run
for 24 hours.
AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS INTERPRETA-
USED TION
SKIN

 Color Inspection Light brown, tanned Light brown Normal

sin (According to race)

 Color Uniformity Inspection Generally uniform Generally uniform Normal

except in areas
exposed to sun

 Edema Inspection No edema (+) grade 4 pitting Not normal Excess fluid
Palpation edema on both buildup in
extremities. the tissue
cause by
decrease
oncotic
pressure due
to decrease
albumin level
(16 g/L)

 Temperature Palpation Normally warm to Normal

touch 36.9°C

 Texture Palpation Smooth, soft and Normal

Inspection flexible palms and Smooth, soft, and
soles (thicker) flexible palms and
soles (thicker)
 Turgor Palpation Springs back to Normal
previous state Springs back to
(1-2 seconds) previous state
(1-2 seconds)
 Moisture Inspection Skin Normally Dry Normal
Palpation Skin normally dry
NAILS

 Nail plate shape Inspection Convex curvature; Convex curvature; Normal

angle between nail angle between nail
and nail bed is about and nail bed is
160 about 160

 Texture Palpation Smooth Smooth Normal

Inspection

 Color of nail bed Inspection Pinkish Pinkish Normal

 Nail base Inspection Firm Firm Normal

 Capillary refill Inspection White color of nail White color of nail Normal
Palpation bed under pressure bed returned within
(Blanch Test) 2-3 seconds
 should return within
2-3 seconds

 Tissue Inspection Intact epidermis Intact epidermis Normal

surrounding nails
 HAIR

 Color Inspection Varies from races, Black Normal

usually black among
Filipinos

 Hair Strands Inspection Thick hair strands Thinning hair Not normal Due to the
strands effect of
chemotherapy
medication
(hydroxyurea

 Distribution Inspection Evenly distributed Uneven distribution Not normal Patient

experiencing
alopecia due
to his
chemotherapy
and
medication
(hydroxyurea)

 Texture Inspection/ Smooth Smooth Normal

Palpation
HEAD

 Scalp Symmetry Inspection Symmetrical Symmetrical Normal

 Skull Shape Inspection Round Round Normal

 Nodules and Inspection, Absence of nodules No nodules and Normal

masses Palpation and masses masses
FACE

 Symmetry Inspection Symmetrical symmetrical Normal

 Texture Palpation Smooth Smooth Normal

 Facial Inspection Symmetric Facial Symmetrical Normal

Movements movement movement

 Color Inspection Same as body color Light brown Normal

 EYES

 Position Inspection Symmetric position Symmetric Normal

position

 Conjunctiva Inspection Clear, moist and Clear, moist and Normal

smooth. smooth.

 Eyebrows Inspection Hair evenly distributed, Hair evenly Normal

skin intact, symmetric distributed, skin
alignment intact,
symmetric
alignment

Inspection Distributed evenly and Distributed evenly Normal

 Eyelashes
curved outward and curved outward

Inspection Transparent, shiny Transparent, shiny Normal

 Cornea
Inspection Color black, pupils Color black, pupils Normal
 Pupils
(PERRLA) constrict when light constrict when light
passes through passes through

Inspection 2-3 mm 2 mm Normal

 Pupil size
Inspection Skin intact, No lesions, Skin intact, No Normal
 Upper and Lower
same color as the skin lesions, same color
eyelids
as the skin

Inspection White White Normal

 Sclera
Inspection Clearly Visible Clearly Visible Normal
 Iris

EARS

 Auricle Inspection Symmetric position Symmetric position Normal

 Symmetry Inspection Symmetrical Symmetrical Normal

 Size Inspection The same with both The same with both Normal
sides sides

 Texture, elasticity Palpation Mobile, firm and not Firm and no Normal
and areas of tender; pinna recoils tenderness
tenderness after it is folded

 Ear Canal Inspection Free of lesions, Free of lesions, Normal

opening discharge or discharge or
Inflammation inflammation
 Hearing Acuity Inspection Client normally hears Client normally Normal
words when whispered hears words when
whispered
 NOSE

 Shape, size and Inspection Smooth, symmetric Smooth, symmetric Normal

skin color with same color as the with same color as
face the face

 Nasal septum Inspection Close to midline, Close to midline, Normal

thicker anteriorly than thicker anteriorly
posteriorly than posteriorly

 Tenderness, Palpation No tenderness and No tenderness and Normal

masses or lesions lesions
displacements of
bones and
cartilage

 Cilia, hair Inspection Evenly distributed Evenly distributed Normal

 Nares Inspection Oval, symmetric and Oval, symmetric Normal

without discharge and without
discharge
MOUTH AND PHARYNX

 Lips Inspection Pinkish, moist, Pale Not normal Due to

symmetrical decrease in
hemoglobin
(9.3 g/dL)

 Buccal Mucosa Inspection Glistening pink, soft, Glistening pink, Normal

moist soft, moist

 Tongue Inspection Moist, slightly rough Smooth Not normal Absence of

on dorsal surface papillae due
medium or dull red to his
antineoplastic
therapy and
decrease
hemoglobin
(9.3 g/dL)

 Gums Inspection Slightly pink, moist Slightly pink, moist Normal

and tightly fit against and tightly fit
each tooth against each tooth

 Hard And soft Inspection Hard palate-dome Hard palate-dome Normal

palate shape shape
Soft palate- light pink Soft palate- light
pink
TEETH
 Teeth Inspection Firmly set, shiny, no Firmly set, shiny, no Normal
tooth decay tooth decay
 NECK

 Symmetry of Inspection Neck is slightly hyper Neck is slightly Normal

neck muscles, extended hyper extended
alignment of
trachea

 Movement Inspection Neck moves freely Neck moves freely Normal

 Neck muscles for Inspection, Muscles equal in size; Muscles equal in Normal
size, swelling or Palpation no swelling or masses size; no swelling or
masses masses

 Neck range of Inspection Neck moves freely, Neck moves freely, Normal
motion without discomfort without discomfort

 Lymph nodes Palpation Not Palpable Not assessed Normal

 Thyroid gland Palpation Rises freely with Rises freely with Normal
swallowing swallowing

 Trachea Inspection Midline Midline Normal

 Symmetry Inspection Symmetrical Normal Normal

 THORAX AND LUNGS

 Respiratory Inspection Even movement Even Normal

movement Occurs in movement
respiration Occurs in
respiration

 Thorax and Lungs Auscultation Clear Breath Presence of Not normal Due to fluid
Sounds crackles accumulation
in lungs

 Contour Inspection Almost round in Almost round Normal

adults, expands in adults,
bilaterally expands
bilaterally

(POSTERIOR THORAX)
 Color Inspection Same as body color Brown Normal

 Texture Inspection No nodules/ lesions Presence of Not normal Patient’s

Symmetrical foul smelling, prolonged used
yellowish, of chest tube.
cloudy with
blood
discharges

 Symmetry of chest Palpation Both sides take off Right side Not normal Due to
expansion at the same time expands less incomplete
and to the same and lags expansion of
extent behind the left pulmonary tissue
(symmetrical). side on his right lung.
(asymmetrical).

(ANTERIOR THORAX)
 Breathing Pattern Inspection Quiet Orthopneic Not normal Due to the
breathing or resting and tachypneic increase
respiratory rate pressure in the
(Eupneic). blood vessels of
the lung that is
cause by the
growing tumor
in the lungs;
Compensation
on decreased
RBC and oxygen
saturation.

 Symmetry Inspection Symmetrical Right side Not normal Due to

 expands less incomplete
and lags expansion of
behind the left pulmonary tissue
side on his right lung.
(asymmetrical

 Color Inspection Same as body color Brown Normal

 ABDOMEN
ABDOMEN
 Color Inspection Skin same color Skin same Normal
with the rest of color with the
the body rest of the
body

 Symmetry of contour Inspection Symmetrical Symmetrical Normal

 Texture Inspection Smooth Smooth Normal

 Bowel sounds Auscultation Clicks or 15 per minute Normal

gurgling sounds
occur irregularly
and range from
5-35 per minute
UPPER EXTREMITIES
 Symmetry Inspection Symmetrical Symmetrical Normal

 Color Inspection Uniform with Uniform with Normal

skin color skin color

 Texture Palpation Smooth Smooth Normal

 Size Inspection Equal Equal Normal

 Range of motion Inspection Can raise both Can raise both Normal
arms without arms without
pain and pain and
discomfort discomfort

 Swelling and lesions Inspection No edema and Presence of Not normal Excess fluid
lesions edema on buildup in
both the tissue
extremities. cause by
decrease
oncotic
pressure
due to
decrease
albumin
level (16
g/L)
 LOWER EXTREMITIES
 Skin color Inspection Uniform with skin Uniform with skin color Normal
color

 Size (legs) Inspection Equal Equal Normal

 Symmetry Inspection Symmetrical Symmetrical Normal

 Swelling, lesions Palpation No edema and lesions Presence of edema on Not normal Excess fluid
both extremities. buildup in the
tissue cause by
decrease oncotic
pressure due to
decrease albumin
level (16 g/L)
HEART
 Heart sound Auscultation No murmurs or any No murmurs or any Normal
abnormal sound abnormal sound

NEUROLOGIC
Level of Interview Fully conscious, Fully conscious, Normal
Consciousness respond to questions respond to questions
quickly, perceptive of quickly, perceptive of
events events
Behavior and Interview Makes eye contact Makes eye contact Normal
appearance with the examiner, with the examiner,
hyperactive expresses hyperactive expresses
feelings which feelings which
response to the response to the
situation situation
MANNERISM, ACTIONS AND LANGUAGE
Voice inflection Interview Clear and strong Not clear and loud Not normal Due to malaise
Tone Interview Fluent and articulated Fluent and articulated Normal
Manner and speech Interview Can give appropriate Can give appropriate Normal
answers to questions answers to
questions
MENTAL STATUS
Orientation Interview Oriented with three Oriented with three Normal
(3) spatial aspects (3) spatial aspects
TIME
Recall recent and Interview Recall events readily, Recall events readily, Normal
remote memory immediately recalls immediately recalls
remote information remote information
Judgment and Interview Can make logical Can make logical Normal
thought decisions decisions