Physical Examination Body Part Skin Normal Findings a. Skin is uniform whitish pink or brown color b. No Bleeding c.

No area of increased vascularity and ecchymosis d. No skin lesions present except for freckles birthmarks or moles which may be flat or elevated e. Skin is dry with a minimum of perspiration. f. Warm & equal bilaterally. Skin is dry Normal Normal Normal Actual findings Normal Normal Normal Interpretation & Analysis Skin may be dry because of frequent urination that leads to dehaydration.

g. Hands & skin slightly cooler than the rest of the body h. Skin surfaces non-tender

Normal

Texture: i. Smooth even & firm except where there is significant hair growth.

Normal

Normal Skin turgor: j. When released, should return to original contour rapidly. k. Scalp and Hair Edema not present Normal

a. Dark black to pale blonde; may turn gray or white; may be chemically changed b. Terminal hair found in the eyebrows, eyelashes, & scalp & in pubic areas after puberty. c. No signs of infestation or lesions.

Normal

Normal

d. Seborrhea/dandruff may be present. e. Hair may feel thin, straight, coarse, thick or curly, shinny and resilient. Nails a. Have a pink-cast in light-skinned and brown in dark skinned. b. Capillary refill present (should return to normal 2-3 sec.) Normal Normal

c.

Surface is smooth and slightly rounded or flat curved nails are normal

Normal

d. Uniform nail thickness throughout: no splintering or brittle edges. e. Angle approx. 160 f. Eyes Firm nail base
o

Normal

Normal Normal Normal

a. Symmetrical with no drooping, infection tumors or other abnormalitites. b. Visual acuity: 20/20 c. Sclera: White in light skinned w/o exudates, lesions or forein bodies. In dark-skinned, may have brown patches d. Pupils: equally round, reactive to light and accommodation; 2-6mm e. No tearing swelling or discharge

Normal Normal

Normal

Normal Normal Normal Normal Normal Normal Normal Normal

Ears

a. Match flesh color of the rest of the skin. b. Central position c. Proportional

d. No redness lesions, swelling, tenderness e. Should not complain of pain or tenderness Nose a. Symmetrical midline of the face b. Without swelling, bleeding, lesions or masses c. Patent nostrils

Normal Normal Normal Normal

d. No pain or discomfort noted Mouth a. Breath smells fresh b. Lips and membranes pink and moist with no lesions or inflammation. c. Tongue is midline Pink, moist, rough without lesions. d. Symmetrical: moves freely e. Gums have pale-red strippled surface f. Neck No swelling or bleeding

Normal

Normal Normal Normal Normal Normal

a. Symmetrical with head in central position b. Able to move head without discomfort or noticeable limits c. Muscles should be symmetrical without

Normal

palpable masses or spasm. Chest a. Without lesions, skin intact b. Quiet, rhythmic and effortless breathing. c. No pulsations masses thoracic tenderness present. d. Normal lung tissue produces resonant sound, diaphragm has dull sounds. e. Bronchial, bronchovesicular or vesicular breath sounds Breast
a. b. The overlying the breast should be even. May or may not be completely symmetrical at rest. c. The areola is rounded or oval, with same color, (Color varies from light pink to dark brown depending on race). d. Nipples are rounded, everted, same size and equal in color. e. No orange peel skin is noted which is present in edema. f. The veins maybe visible but not engorge and prominent. g. h. No obvious mass noted. Not fixated and moves bilaterally when hands are abducted over the head, or is learning forward. i. No retractions or dimpling.

Normal Normal Normal

Normal

Normal

Abdomen

a. Abdominal contour flat or rounded.

Over sized Abdomen

Over sized abdomen and stretch marks are due to gestational period.

b. Symmetrical c. Uniform in color or pigmentation

Not normal Normal Normal Stretch marks Normal

d. No abdominal scars. e. No striae f. Intermittent gurgling sounds throughout abdominal quadrants. g. Tympany predominant sound heard h. No organ enlargement palpable or any masses, bulges or swelling.

Normal Normal

Suprapubic Area Genitalia

a. Without lesions b. Urinary bladder palpable and not tender a. Pubic hair distributed in triangular form. b. More coarse than scalp hair c. No nits or lice

Normal Normal Normal Normal Normal Normal

Upper Extremities Lower Extremities

a. Without lesions, scars or inflammation

a. Without lesions, scars b. No edema

Normal Normal