Area Assessed 1.

Skull

Technique Used Inspection

Normal Findings Rounded, (normocephalic and symmetric with frontal, parietal and occipital prominences); smooth skull contour Smooth, absence of nodules or masses Scalp is lighter than the skin tone, no foul odor, no sign of dandruff and no lesions. Hair is evenly distributed, thick, silky, resilient hair, no infection or infestations Symmetric or slightly asymmetrical facial features; symmetric nasolabial folds, symmetric facial movements Eyebrows have evenly distributed hair, symmetric, equal movement Eyelashes are curled slightly outward, equally distributed Eyelids are intact, no discharge and discoloration, close symmetrically, bilateral blinking

Actual Findings

Analysis

Palpation 2. Hair and Scalp Inspection

3. Face

Inspection

4. Eyes

Inspection

Palpation

Pupils

Inspection

Bulbar conjunctiva is transparent, sclera appears white Palpebral conjucntiva is shiny, smooth and pink/red Cornea is transparent, shiny, smooth No edema or tenderness over lacrimal gland; no edema or excessive tearing on the lacrimal sac and nasolacrimal duct Black in color, equal in size, normally 3-7 mm, round, smooth border, iris flat and round Direct and consensual reaction to light: Illuminated and nonilluminated pupil constricts. Reaction to accommodation and convergence: pupil constricts when looking at near objects; dilate when looking at far objects; converges when near object is moved toward nose. Client can see objects in the periphery while looking straight ahead Both eyes coordinated,

Peripheral visual fields Six

Inspection Inspection

cardinal position of gaze Visual acuity (Snellen) 5. Ears

move in unison, with parallel alignment. Inspection Inspection 20/20 vision Color same as facial skin, symmetrical, auricle aligned with outer canthus of the eye about 10 degree from vertical External ear canal has dry cerumen, grayishtan color, no pus, blood or lesions Auricles are mobile, firm and not tender; pinna recoils after its folded Normal voice tone is audible Sound is heard in both ears or is localized at the center of the head (Weber negative) Air conduction is greater than bone conduction (Rinne positive) External nose is symmetric and straight, no discharge or flaring, uniform in color Nasal patency: Air

Palpation Hearing Tests: - Normal voice sound - Weber Test Rinne Test Inspection

6. Nose and Sinuses

Palpation

moves freely as the client breathes through the nares. Nasal lining is mucosa pink, clear, has no watery discharge, no lesions, nasal septum is intact and in midline. External nose is tender, no lesions. Maxillary and frontal sinuses are not tender.

7. Mouth and Oropharynx - Lips and Buccal Mucosa

Inspection and Palpation

Teeth and gums

Inspection

Tongue

Inspection

Palpation Mouth floor and Inspection

Uniform pink in color, soft, moist, smooth texture. Symmetric, abilty to purse lips. Buccal mucosa is moist, smooth soft, glistening and elastic texture. 32 adult teeth. It is smooth, white and shiny. Gums are pink, moist and firm. No retraction of gums. It is centered, pink color, smooth, lateral margins; no lesions, raised papillae. Moves freely with no tenderness. Smooth with no palpable nodules. Mouth floor and roof has a smooth tongue base

roof Hard and soft palate Uvula Tonsils and oropharyn x

Inspection

Inspection Inspection

8. Neck

Inspection

Lymph nodes Trachea

Palpation Palpation

with prominent veins. Light pink, smooth (soft palate); lighter pink, more irregular texture (hard palate) Positions in midline with soft palate Oropharynx has pink and smooth posterior wall. Tonsils are pink and smooth, no discharge and is of normal size. Gag reflex: Present Neck muscles are equal in size, head centered. Head movement is coordinated, smooth movements with no discomfort. Muscle strength is equal. Not palpable. Central in placement in midline of the neck; spaces are equal on both sides Not visible on inspection Lobes may not be palpated. If palpated, lobes are small, smooth, centrally located, painless and rise freely with swallowing. Anteroposterior to

Thyroid Gland

Inspection Palpation

9. Posterior

Inspection

Thorax

Palpation

transverse diameter in ratio of 1:2, chest is symmetric, spine vertically aligned, straight, right and left shoulders and hips are at same height. Skin intact, uniform temperature, no tenderness, no masses. Chest excursion: Full and symmetric expansion, thumbs move at equal distance and at the same time, about 3-5 cm. Vocal Fremitus: Bilateral symmetry, heard most clearly at apex of the lungs. Percussion notes are resonance, except over scapula. Dullness in ribs. Vesicular sounds over lung periphery; bronchovesicular sound between scapulae and sternum; bronchial sound over trachea, not hear over lung tissue. Breathing is quiet and effortless, coastal angle is less than 90 degrees, and the ribs enter the spine at about 45

Percussion Auscultation

10. Anterior Thorax

Inspection

Palpation

degree angle. Chest excursion: Full and symmetric expansion, thumbs move at equal distance and at the same time, about 3-5 cm. Vocal Fremitus: Bilateral symmetry, normally decreased over heart and breast tissue. Notes are resonance down to the 6th rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull over hearts and liver, and tympany over stomach. Bronchial sounds over Trachea. Bronchovesicular and vesicular sounds on the anterior chest. No pulsations at aortic, pulmonic, tricuspid, and apical (but may be visible in 50% adults) areas. Aortic pulsations. S1and S2 is usually heard at all sites; S1 is usually louder at apical area; S2 is usually louder at base of the heart.

Percussion

Auscultation

11. Heart, carotid arteries, Jugular veins

Palpation

Auscultation

- Carotid

Palpation

Artery
- Jugular veins

Symmetric pulse volumes, full pulsations, thrusting quality. Veins are not visible. Males: breasts even with the chest wall. Skin uniform in color, smooth and intact, striae, moles or nevi. Areola is round and symmetric. Color varies. Nipples are round, everted and equal in size. Similar in color, soft and smooth, point in same direction. No discharge. No tenderness, masses, nodules or nipple discharge. Unblemished skin, uniform color; flat, rounded or scpahoid, symmetric contour, symmetric movements. Audible bowel sounds; absence of arterial bruits; absence of friction rubs. Tympany over stomach, dullness over liver and spleen or a full bladder. No tenderness, relaxed abdomen with smooth, consistent tension. 6-12 cm in the

12. Breast and Axillae

Inspection Inspection

Palpation 13. Abdomen Inspection

Auscultation

Percussion Palpation
- Liver

Percussion

Palpation 14. Upper extremities Inspection Palpation

15. Lower extremities

Inspection Palpation

midclavicular line; 48cm at midsternal line. May not be palpable, border feels smooth. Equal size on both sides, no contractures, no tremors. Smooth coordinated movements, equal strength on each body side. No tenderness. Equal size on both sides, no contractures, no tremors. Smooth coordinated movements, equal strength on each body side. No tenderness. Source: