PHYSICAL ASSESSMENT 1

I. PHYSICAL ASSESSMENT

AREA FINDINGS INTERPRETATION

CRANIAL
NERVE The patient can identify Normal
FUNCTION the smell of an alcohol.
Patient correctly
Olfactory identifies the scent
(CN I) presented to each
nostril.

Optic (CN II) The patient has no Normal

difficulty to read
anything.

Oculomotor The patient has Oculomotor nerve enters the orbit via
(CN III) difficulty to perform the the superior orbital fissure and
six cardinal fields of innervates muscles that enable most
gaze and cannot follow movements of the eye and that raise
the six ocular the eyelid. The nerve also contains
movements. fibers that innervate the muscles that
enable pupillary constriction and
accommodation. Once it damage it
affects the persons ability of muscle
eye movement.

Trochlear (CN Patient has limited eye Limited eye movement through the
IV) movement and has six cardinal fields of gaze is due to
difficulty in following increase Intracranial pressure which
the six cardinal fields. compresses the nerve that results to
damage.
It is the only cranial nerve that
emerges dorsally from the brain (near
the back), giving it the longest
pathway. It is the smallest nerve to
service the eye. CN IV passes
through the superior orbital fissure,
and it provides motor function, or
movement.

Trigeminal Temporal and masseter Normal

(CN V) muscle contract
bilaterally.
The client correctly
identifies sharp and dull
stimuli and light touch
to the forehead, cheeks
and chin
PHYSICAL ASSESSMENT 2

Abducens (CN The patient has Abducens nerve controls the

VI) difficulty to perform the movement of a single muscle, the
six cardinal fields of lateral rectus muscle of the eye. It has
gaze. been damaged due to increased
intracranial pressure.

Normal
Facial (CN Face is symmetrical
VII)

Acoustic (CN Patient hears whispered Normal

VIII) words from 1-2ft

Glossopharyng Uvula and soft palate Normal

eal (CN IX) does rise symmetrically
on phonation..

Vagus (CN X) Weak gag reflex Indicates that there is damage or

lesions of cranial nerve IX and X.
The vagus nerve historically cited as
the pneumogastric nerve which
carries various types of axons. It
provides parasympathetic innervation
to glands of mucous membranes of
the pharynx, larynx, organs in the
neck, thorax, and abdomen.

Reference: Health assessment in

Nursing by Janet Weber and Jane
Kelly 2010 3rd edition p.476.

Spinal There is symmetric Normal

accessory (XI) muscle contraction of
the trapezius muscle

Hypoglossal Can protrude tongue at Normal

(CN XII) midline
 PHYSICAL ASSESSMENT 3

AREA METHOD FINDINGS INTERPRET IMPLICATI

ATION ON

INTEGUMENTARY

Skin
Inspection Skin color is tan. Abnssormal Due to falling
and palpation Has equally warm and being
temperature on both thrown off by
arms and legs. the motorcycle
There is a presence during the
of abrasions on accident
right and left
shoulder, and right
thigh.

Hair Inspection Hair color is white Normal

with smooth and
fine hair strands and
is equally
distributed.

Nails Inspection Nail beds pinkish in Normal

color.
There is no
presence of nail
clubbing.
Capillary refill time Normal
< 3 sec.
HEAD
Skull and Face Inspection Head is of a regular Normal
and palpation shape.
Presence of Abnormal Skin disruption
abrasions and that resulted
lacerations on the from the
head approximately trauma of VA.
3cm in length.

Eyes and Vision Inspection Eyes are aligned; Abnormal Due to results
There is a presence from trauma
of hematoma on the secondary to
right eye vehicular
accident.
Extra ocular
movement (EOM) Normal
is intact.
 PHYSICAL ASSESSMENT 4

Ears and Hearing Inspection Symmetrical ears Normal

and palpation and equal in size
aligned on the outer
canthus of the eye.
No presence of
tenderness, masses
and drainage
clogged/ cerumen.
Pinna recoils
immediately.

Mouth and Inspection Lips, oral mucosa Normal

Oropharynx and gums are
pinkish in color.
No suspected
lesions or masses
on tongue, gums,
hard and soft palate
and tonsils. Uvula
is in the middle,
tonsils are pink
without
hypertrophy.
Tongue easily
move in all
directions, pinkish
with presence of Normal
whitish spots,

With intact gag

reflex

Normal

Lymph nodes Palpation Lymph nodes are Normal

non-palpable.

Palpation Normal
 PHYSICAL ASSESSMENT 5

Trachea and thyroid Trachea in midline

gland position.

Thyroid gland lobe Normal

non- palpable, no
evidence of
enlargement and
rises as patient
swallows.

RESPIRATORY Inspection Symmetrical Normal

SYSTEM respiratory effort
without the use of
Chest accessory muscles

Lungs Inspection Thorax rise and fall Normal

with inspiration and
Auscultaion expiration.

Resonant
percussion
throughout.

Breath sounds
arenormal with no
extra sounds.
CARDIOVASCULAR Inspection No jugular vein Normal
SYSTEM distension at 45
Auscultation degree.

No extra heart
sounds and no
murmurs heard.

Aortic pulsation
normal, no bruit
sounds.
DIGESTIVE SYSTEM Inspection Abdomen is flat and Normal
Abdomen contour
Auscultation
No masses and
Percussion absence of
organomegaly.
Palpation
No tenderness to
palpation.

Kidney and spleen

are not palpable
 PHYSICAL ASSESSMENT 6

With normal bowel

sounds:
RLQ: 2 clicks/15
seconds
RUQ: 4 clicks/15
seconds
LUQ: 3 clicks/15
seconds
LLQ:3 clicks/15
seconds
MUSCULOSKELETA Muscle Right arm: 5/5 Normal
L SYSTEM Strength Right Leg: 5/5

Muscle Strength Left arm: 5/5

Left Leg: 5/5

Glasgow Coma Scale

Eye Opening
Inspection Response to 3 Due to the
Command feeling of
Verbal Response drowsy
Inspection Oriented 5
Normal

Motor Response
Localizes pain
Inspection 5
and Palpation Due to results
from trauma
secondary to
vehicular
accident.
PHYSICAL ASSESSMENT 7