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Physical Examination Body Parts Skin Method Normal Findings Actual Findings Light brown in color Interpretation Normal for Filipino lineage
Inspection Color: Varies from / Palpation light to deep brown; from ruddy pink to light pink; from yellow overtones to olive Uniformity: Generally uniform except in areas exposed to the sun; areas of lighter pigmentation (palms, lips, nails beds) in dark skinned people. Skin Lesions: Freckles, some birthmarks, some flat and raised nevi (moles) No abrasions or other lesions.
Normal
Skin Turgor: When pinched. Skin springs back to previous state. Hair and Scalp Inspection Evenness of Growth: Evenly distributed hair. Thickness/ Thinness, Color, Length: Thick hair. Infestations: No infections or infestations
When pinched, skin springs quickly back to previous state Evenly distributed hair Hair is short, thick and black in color Presence of nits Indicates Pediculosis capitis infestation Normal Normal Normal
Scalp is smooth and free from lesions Nails Inspection Shape: Convex curvature, angle between nail bed about 160 degrees.
With healed scars Convex curvature, angle between nail bed about 160 degrees.
Palpation
Texture: Surface is smooth, and slightly rounded or flat. Uniform nail thickness throughout
Surface smooth Normal and slightly rounded Uniform nail thickness. Normal Normal
Firm nail base Nail Bed Color: Highly vascular and pink in light skinned clients.
Firm Nail base Highly vascular and pink in light skinned clients.
Normal Normal
Capillary refill present Capillary refill Normal in 2- 3 seconds Cut short and clean Skull and Face Inspection Skull Size, Shape, and Symmetry: Rounded (normocephalic and symmetric, with frontal, parietal and occipital); Smooth skull. Edema not present of 2 seconds Long and with Indicates poor presence of dirt hygiene Rounded Normal (normocephalic and symmetric, with frontal, parietal and occipital); Smooth skull. With nonpitting facial edema Normal Indicates fluid retention secondary to AGN complications Palpation Nodules/ Masses/Lesions: Smooth, uniform Smooth, uniform consistency of Normal
consistency of nodules or masses. Inspection Facial Features: Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds Facial Movements: Symmetric facial movements
nodules or masses.
Normal
Normal
Method
Normal Findings
Actual Findings
Interpretations
Inspection External Structures Eyebrows: Hair evenly Hair evenly distributed; skin intact eyebrows symmetrically aligned; equal movement. distributed; skin intact eyebrows symmetrically aligned; equal movement. Eyelashes: Equally distributed; curled slightly outward. Equally distributed; curled slightly outward. Normal Normal Normal
Eyelids: Skin intact; no Skin intact; no discharge; no discoloration. Lids close symmetrically discharge; no discoloration. Lids close symmetrically Inspection Pupil: Black in color; equal in size; normally 3 to 7 mm in diameter; round, smooth border, inflate and round. Black in color; equal in size; normally 3 to 7 mm in diameter; round, smooth border, inflate and round. Inspection Reaction to Light: Pupils: equally round, reactive to light and accommodation; Pupils: equally round, reactive to light and accommodatio n; Both eyes coordinated, move in unison, with parallel alignment Eyes coordinated, move in unison, parallel alignment Visual Acuity: 20/20 Transient loss of eyesight
Normal
Normal
Normal
Normal
blood pressure (160/100 mmHg) as a complication of AGN Ears and Hearing Inspection Auricles Color same as facial skin Symmetric position Color same as facial skin Symmetric position Mobile, firm and not tender External ear Canal Inspection and Tympanic Membrane Distal third contains Distal third follicles and glands. Dry cerum, brown Dry cerum, brown Normal Normal hair follicles and glands contains hair Mobile, firm and not tender Normal Normal Normal
Inspection
Nose: Symmetric and straight Symmetric and straight No discharge or flaring uniform color. No discharge or flaring uniform color. Not tender; no lesions Not tender; no lesions Lining of Nares: Mucosa pink Clear, watery discharge Mucosa pink Clear, watery discharge No lesions Nasal Septum: Nasal septum intact and Nasal septum in midline intact and in midline No lesions Normal Normal Normal Normal Normal
Inspection
Lips and Buccal Mucosa Uniform pink color. Soft, moist, smooth texture symmetry of contour. Ability to Pink in color Soft, moist, smooth texture symmetry of Normal Normal
purse lips
Inner lips and Buccal Mucosa Uniform pink color Teeth and Gums 20 deciduous teeth for children 3 years old and above 32 teeth for adults 18 deciduous teeth At 7 years old, clients milk teeth fall off and start developing permanent teeth Smooth, white, shiny tooth enamel Smooth, yellowish tooth enamel Normal Uniform pink color Normal
Inspection
Pink gums, Moist firm Pink gums, texture to gums Tongue/ floor of Mouth Central Position Central Tongue Pink in color, moist, slightly rough, thin Pink in color, Position Moist firm texture to gums
Normal
Normal
Normal
whitish coating
Neck Inspection
Neck Muscles Muscles equal in size; head centered Equal muscle strength Muscles equal in size; head centered Equal muscle strength Palpation Lymph Nodes Not palpable Subparotid lymph nodes palpable Indicates presence of infection Normal Normal Normal
Posterior Thorax Chest symmetric, brown in color Skin intact; uniform temperature Anterior Thorax Palpation Skin intact; uniform temperature Skin intact; uniform temperature Inspection Normal breathing pattern for patients 67 years old: 20- 30 RR:22 cpm Skin intact; uniform Normal Normal Chest symmetric, brown in color
cpm
temperature
Abdomen
Inspection
Normal
Uniform in color or pigmentation. Uniform in color. No abdominal scars No striae No scars; no striae
Normal
Normal
Auscultation Intermittent gurgling Gurgling sounds throughout sounds in abdominal quadrants. abdomen
Normal
High-pitched, 4 bowel gurgling noises that sounds in a occur approximately minute every 5 15 seconds. No friction rubs/ audible sound bruits
Normal
Percussion
Normal
Palpation
Normal
Genitalia
Inspection
N/A
N/A
Upper Extremities
Inspection
Normal
Lower Extremities
Inspection Palpation
Normal Normal