PARTS TO

BE
TECHNIQU NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
ASSESSED E
AND
INTERPR
ETATION

Inspect, Varies from light to

Palpate brown. Generally
SKIN uniform except in areas
exposed to sun. No
oedema noted. No
lesions or abrasions,
freckles, birthmarks,
scars. Moisture in skin
folds and axilla,
generally dry. Uniform
and within nomad range.
When pinched, skin
springs back to previous
state, with good skin
turgor.

Inspect Evenly distributed hair.

Thick hair. Silky and
HAIR resilient hair. No
infection and
infestations. With
equally distributed hair
in the body.

Inspect Convex curvature.

Smooth. Highly vascular
NAILS and pink. With intact
epidermis. Prompt return
of pink or usual color.
(Generally less than 4
seconds)

SKULL AND Inspect, Rounded and

FACE palpate symmetrical and with
smooth skull contour.
 Smooth, absence of
nodules and lesions.
Symmetrical facial
features. No oedema
noted. With symmetrical
facial movement.

Inspect, Eyebrows hair evenly

Palpate distributed, skin intact.
EYES Eyelashes equally
distributed, curled
slightly upward. Eyelids
skin intact, no discharges
or discoloration. Bulbar
conjunctiva transparent,
sclera appears white.
Palpebral conjunctiva
shiny, smooth, color
pink. Lacrimal gland no
oedema or tenderness.
Lacrimal sac and
nasolacrimal duct has no
oedema or tenderness.
Cornea transparent,
shiny and smooth. Client
blinks when the cornea is
touched. Pupils black in
color and equal in size.
Illuminated pupil
constricts, reactive to
light. Pupil constrict
when looking at near
objects and dilate when
looking at far objects.
Pupil converge when
near object is moved
toward the nose.
PERRLA. When looking
straight ahead, client can
see objects in periphery.
Both eyes coordinated,
 move in unison with
parallel alignment. Able
to red newsprint.

Inspect, Auricle aligned with

palpate outer canthus of eye,
EARS color same as facial skin,
symmetrical. Mobile,
firm and not tender.
Pinna recoils after it is
folded. Able to hear
ticking watch. Able to
hear sound equally in
both ears. Air
conduction is longer than
bone conduction.

NOSE AND Inspect, Symmetric and straight,

SINUSES palpate no discharges or flaring.
Not tender, no lesions.
Air moves freely as the
client breathes through
the nares. Mucosa pink,
no lesions or discharges.
Intact facial sinuses, no
tenderness or
discomfort.

Inspect, Pink color, soft, moist,

palpate smooth, symmetry of
MOUTH contour. Able to do purse
lips. 32 adult teeth
smooth, white shiny
tooth enamel. Intact
dentures. Central
position, pink moves
freely. Smooth tongue
base with prominent
veins and no palpable
nodules. Same color of
buccal mucosa and floor
 of the mouth. Light pink,
smooth soft palate,
lighter pink hard palate
with more irregular
texture. Uvula
positioned in midline of
soft palate. Oropharynx
pink and smooth, no
discharges and positive
gag reflex.

Inspect, Muscle equal in size with

palpate, coordinated smooth
NECK movements with no
discomforts. Muscle
strength equal. Lymph
nodules not palpable.
Trachea is in central
placement in midline of
neck spaces are equal on
both sides. Thyroid
gland ascends during
swallowing and not
visible on inspection.
Lobes not palpated.

THORAX Inspect, Posterior:

AND LUNGS palpate,
percuss, PA to TD 1:2 ratio. Chest
auscultate symmetrical. Spine
vertically aligned. Skin
and chest wall intact with
uniform temperature, no
tenderness or masses.
Full and symmetric chest
expansion, thumbs
separate 3-5cm during
deep inspiration.
Bilateral symmetry of
vocal fremitus.
Percussion notes
 resonate except over
scapula. Vesicular and
bronchovesicular
breathe sounds hear.

Anterior:

Quiet rhythmic and

effortless respirations.
Skin and chest wall
intact with uniform
temperature, no
tenderness or masses.
Full and symmetric chest
expansion, thumbs
separate during deep
inspiration. Bilateral
symmetry of vocal
fremitus decreased over
heart and breast tissue.
Percussion notes
resonates doth to 6th rib
at the level of the
diaphragm but are flat
over muscles and bones,
dull on areas over the
heart and the liver and
tympanic over stomach,
vesicular and
bronchovesicular
breathe sounds heard.

Inspect, No pulsations except for

palpate, apical area. S1(lub) is
HEART auscultate heard at all sites, louder
at the apical area.
S2(dub) is heard at all
sites, louder at the base
of the heart.
BREAST/ Inspect, Breasts even with the
AXILLAE palpate chest wall. Skin uniform
in color, smooth, intact,
no retractions. Areola is
round in shape,
bilaterally the same color
from light pink to dark
brown. Nipples round,
everted and equal in size,
similar in color, soft and
smooth, point in the
direction, no discharges.
No tenderness, masses or
nodules and discharges.

ABDOMEN Inspect, Skin is uniform in color,

auscultate flat, rounded, scaphoid,
percuss, symmetric contour and
palpate, movements. No visible
vascular patterns. With
audible bowel sounds.
Tympany over the
stomach and gas-filled
bowels; dullness over the
liver and spleen or a full
bladder. No tenderness,
with relaxed abdomen.

MUSKULOS Inspect, Equal muscle size on

KELETAL palpate both sides of the body,
ASSESSMEN no contractures, no
T tremors. Firm muscles,
smooth coordinated
movement, equal
strength on each body
side. No deformities, no
tenderness or swelling.
Able to move selected
body parts.
NEUROLOGI No difficulty in
CAL speaking. Able to answer
ASSESSMEN questions correctly. Able
T to correctly repeat series
of numbers. Able to
count backward and
calculate the correct
numbers upon
subtraction. Able to
elicit patellar reflex. Has
upright posture and
steady gait. Repeatedly
and rhythmically
touches the nose.
Demonstrates bilateral
equal coordination. Able
to feel light tickling or
touch sensation. Able to
discriminate “sharp” and
“dull”. Able to
discriminate between
“hot” and “cold”
sensations. Can readily
determine the position of
finger. Able to identify
objects by touching
without seeing.