E.

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.

Generally uniform except in areas exposed to the sun

Normal

One coin-sized birthmark above the left elbow Scars Present

Present since birth

Due to old scrapes and abrasion wounds

Skin Moisture: Moisture is equal on all body parts.

Skin is moisture is equal on all body parts. 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.

Lesions from old wounds due to boils Normal

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

Inspection No splintering or brittle No splinters or edges. brittle edges

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.

Symmetric facial features symmetric nasolabial folds.

Normal

Symmetric facial movements

Normal

Body Part Eye Structures and Visual Acuity

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

Due to sudden increase in intracranial or

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

Nose and Sinuses

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

Mouth and Oropharynx

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

contour. Ability to purse lips Normal

Inspection and Palpation

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

moist, slightly rough, thin whitish

Moves feely; no tenderness

coating Moves feely; no tenderness

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

Thorax and Lungs Inspection

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

Abdominal contour flat or rounded, symmetrical .

Abdominal contour rounded, symmetrical.

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

Tympany, predominant heard

Normal

Palpation

No organ enlargement palpable, or any masses, bulges, or swelling

No organ enlargement palpable, or any masses, bulges, or swelling

Normal

Genitalia

Inspection

No nodule, inflammation, no discharges

N/A

N/A

Upper Extremities

Inspection

Without lesions, scars or inflammation

Without lesions, scars or inflammation Without lesions, scars No edema

Normal

Lower Extremities

Inspection Palpation

Without lesions, scars No edema

Normal Normal