BODY PART Technique NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

used

Skin Inspection Uniform in color; no

abrasions or any lesions

Well moistened skin.

HEAD Round or normocephalic;

smooth, absence of
SKULL & Inspection nodules or masses;
FACE Palpation symmetric facial
movements.
HAIR Inspection Even distribution of hair,
resilient thick hair with
no signs of infections or
infestations.
Eyebrow Inspection Evenly distributed hair;
eyebrows symmetrically
aligned;

Eyes Inspection Lids close symmetrically;

shiny smooth, pinkish
conjunctiva; no edema or
tenderness.

Equally distributed,
Curled slightly outward

Eyelashes Inspection Skin intact,

No discharge,

Eyelids Inspection No
discoloration,
Lids close symmetrically

Black in color, equal in

size normally 3-7 mm in
Pupils (color , Inspection diameter,
shape and round smooth border , iris
symmetry of flat and round.
size)
EAR Inspection color same as facial skin

symmetrical; mobile,
firm and not tender;

No notable discharges
 normal voice tones
audible
NOSE AND Inspection Symmetric and straight;
SINUSES
no discharge or flaring;
not tender, no lesions.

Uniform in color

Air moves freely as the

patient breaths through
the nares.

No tenderness in
maxillary and frontal
sinuses
MOUTH Inspection Uniform in pink color;
symmetrical lips.

TONGUE Inspection in central position; pink

in color

moves freely with no

tenderness

Smooth tongue base with

prominent veins
Smooth with no palpable
nodules

Uvula positioned in
midline of soft palate.

gag reflex present

TEETH Inspection 32 adult teeth, smooth,

white, shiny tooth enamel

no retraction of gums
 NECK Inspection Coordinated, smooth
MUSCLES Palpation movement with no
discomfort. Has equal
muscle strength.

Not palpable

Palpation
Lymph nodes
Upper Inspection Muscle:
extremities Palpation Equal size on both sides
of the body

No contractures

Bones:
No skeletal deformities.

Joints:
No swelling, tenderness,
crepitation or nodules.

Moves freely
Thorax and Inspection Posterior thorax:
Lungs Auscultation Symmetry:
Palpation Spine vertically aligned;
spinal column is straight,
right and left shoulders
hips are the same in
height.

Skin intact; uniform

temperature
No tenderness and no
presence of masses

Vesicular and broncho-

Vesicular breath sounds

Anterior thorax:
Quite, rhythmic, and
effortless respirations

No tenderness and no
presence of masses
Abdomen Inspection Unblemished skin
Auscultation Uniform in color
Palpation Flat, rounded or scaphoid

Symmetric movement
caused by respiration

Audible bowel sound

GENITALS
 asymmetric (left testis is
Scrotum usually lower) no lesions,
nodules, swellings and
inflammation

Prostate gland no enlargement, no

nodules

Inguinal No swelling; no palpable

bulges
Lower Inspection Muscle:
extremities Palpation Equal in size on both
sides of the body

No contractures.

No lesions, swelling and

inflammation

Bones:
No skeletal deformities.

Joints:
No swelling, tenderness,
crepitation or nodules and
moves freely