Body Part

NORMAL FINDINGS

ABNORMAL FINDINGS

Analysis, interpretation, comments

General Appearance & behavior

Skin

Hair

( ) Clean & well groomed ( ) Alert & active ( ) Responds appropriately/ cooperative ( ) Maintains eye contact ( ) Logical sequence ( ) evenly colored skin tones ( ) brownish in color ( ) smooth without lesions ( ) skin is smooth ( ) moist to dry ( ) without edema ( ) easily and immediately returns to its original position. ( ) uniform temperature ( ) natural hair color ( ) evenly distributed ( ) thick/strong ( ) clean and dry ( ) smooth, silky & resilient ( ) no infestation/infection

( ) excessively thin or obese ( ) uncoordinated movements ( ) body odor present ( ) breath odor ( ) appears stressed ( ) has fear, anxiety, or anger ( ) lack of eye contact

NORMAL

(( ) evenly colored skin tones ( ) brownish in color ( ) smooth without lesions ( ) skin is smooth ( ) moist to dry ( ) without edema ( ) easily and immediately returns to its original position. ( ) uniform temperature

NORMAL

( ) nutritional deficiencies may cause patchy gray hair in some clients ( ) flakes, sores, nits, ring worm ( ) presence of infestation ( ) thin ( ) brittle ( ) dull ( ) dry hair

NORMAL

Nails

( ) convex, 160 ( ) smooth ( ) clean ( ) groomed ( ) pink tones ( ) intact epidermis ( ) prompt return, <4 secs ( ) rounded ( ) smooth/ absence of nodules ( ) symmetric facial features ( ) symmetric nasolabial folds ( ) symmetric facial movements ( ) evenly distributed ( ) curled outside ( ) transparent ( ) capillaries evident ( ) shiny, smooth, red or pink ( ) no edema and tearing ( ) no tenderness ( ) transparent, shiny, and smooth ( ) arcus senilis, 40 above ( ) sensitive ( ) black ( ) equal size ( ) constrict at near ( ) dilate at far

Skull and Face

( ) dirty ( ) broken ( ) pale ( ) cyanotic ( ) jaundice ( ) white color suggest infection ( ) short-ragged nails ( ) concave shape ( ) clubbing ( ) increased skull size ( ) sebaceous cysts ( ) increased/ thinning of hair (eyebrows) ( ) asymmetric facial movements/ nasolabial folds

NORMAL

NORMAL

NORMAL

Eyebrows and eyelashes Conjunctiva

( ) loss of hair ( ) turned inward ( ) jaundice ( ) pallor

NORMAL

NORMAL

Lacrimal gland and sac Cornea

( ) swelling and tenderness ( ) excessive tearing ( ) opaque, not smooth ( ) arcus senilis, 40 below ( ) cloudy, and has shadows

NORMAL

NORMAL

Pupils

( )cloudiness ( ) not constricting ( ) not dilating

NORMAL

Visual Fields

Ears and hearing acuity

Nose and sinuses

Lips and buccal mucosa Teeth and gums

Tongue/ floor of mouth

( ) can look at periphery ( ) coordinated movements ( ) able to read newsprint (near vision) ( ) cant read and see clearly at far ( ) auricle aligned in outer canthus of eye ( ) pinna recoils ( ) no tenderness ( ) normal voice tones audible ( ) can hear both ears ( ) symmetric ( ) no discharge or flaring ( ) no tenderness ( ) can breath through nares ( ) mucosa pink ( ) no tenderness on sinuses ( frontal, maxillary) ( ) uniform pink color ( ) soft and smooth ( ) ability to purse lips ( ) 32 adult teeth ( ) smooth and white enamel ( ) pink gums ( ) moist and firm gums ( ) central position ( ) pink color ( ) raised papillae

( ) cant look at periphery ( ) uncoordinated movements ( ) difficulty in reading ( ) cant see clearly at far

NORMAL

( ) bluish color of ears ( ) low set ears ( ) tenderness ( ) lesions ( ) unable to hear clearly ( ) not audible ( ) asymmetric ( ) discharge ( ) tenderness ( ) restricted breathing ( ) mucosa red ( ) tenderness on sinuses

NORMAL

NORMAL NORMAL

( ) uniform pink color ( ) soft and smooth ( ) ability to purse lips ( ) 32 adult teeth ( ) smooth and white enamel ( ) pink gums ( ) moist and firm gums ( ) deviated from center ( ) red tongue ( ) swelling, ulceration

NORMAL

NORMAL

NORMAL

Palates and uvula

Oropharynx and tonsils Neck muscles

Lymph nodes Trachea Thyroid gland

( ) smooth tongue base with prominent veins ( ) no palpable nodules ( ) light pink, smooth (soft palate) ( ) lighter pink, more irregular texture (hard palate) ( ) positioned on midline of soft palate (uvula) ( ) pink and smooth ( ) no discharge ( ) present gag reflex ( ) muscles equal in size ( ) coordinated, smooth movements ( ) equal strength (sternocleidomastoid and trapezius) ( ) not palpable ( ) central placement ( ) spaces are equal ( ) not visible in inspection ( ) no nodules and lobes are not palpated ( ) ascends when swallowing ( ) Symmetric ( ) anteroposterior-

( ) no palpable nodules

( ) discoloration ( ) uvula deviated to one side NORMAL

( ) reddened or edematous ( ) inflamed ( ) discharge ( ) unilateral neck swelling ( ) muscle tremors, spasm, stiffness ( ) limited range of motion ( ) unequal strength

NORMAL

NORMAL

( ) palpable ( ) deviated to one side ( ) visible diffuseness or local enlargement ( ) solitary nodules ( ) not movable with swallowing

NORMAL NORMAL

NORMAL

Posterior thorax 1. Shape & symmetry

( ) barrel chest ( ) increased ratio

2. Spinal alignment

3. Palpation

4. Respiratory excursion 5. Vocal fremitus 6. Auscultation Anterior thorax 1. Breathing pattern 2. Palpation

transverse diameter ratio of 1:2 ( ) Vertically aligned ( ) straight ( ) left & right shoulders & hips are at same height ( ) Uniform temp. ( ) skin intact ( ) chest wall intact ( ) not tender ( ) no masses ( ) Full & symmetric chest expansion ( ) Bilateral symmetry of vocal fremitus ( ) Vesicular & bronchovesicular breath sounds

( ) chest asymmetric ( ) kyphosis ( ) lordosis ( ) scoliosis ( ) shoulders and hips not even ( ) skin lesions ( ) areas of fever ( ) lumps ( ) depression ( ) tenderness ( ) asymmetric expansion ( ) increased expansion ( ) decreased expansion ( ) decreased fremitus ( ) absent fremitus ( ) increased fremitus ( ) abnormal sounds

NORMAL

3. Respiratory excursion 4. Vocal fremitus

( ) Quiet, rhythmic, & effortless ( ) Uniform temp. ( ) skin intact ( ) not tender ( ) no masses ( ) Full & symmetric

( ) noisy, arrhythmic, & difficult ( ) skin lesions ( ) areas of fever ( ) lumps ( ) depression ( ) tenderness ( ) asymmetric expansion ( ) increased expansion ( ) decreased expansion ( ) decreased fremitus ( ) absent fremitus ( ) increased fremitus ( ) abnormal breath sounds ( ) abnormal breath sounds

excursion 5. Auscultation (trachea) 6. Auscultation (anterior chest) Heart & central vessels 1. Palpation (carotid artery) 2. Auscultation (carotid artery) 3. Inspection of jugular vein Abdomen 1. Contour & symmetry, liver & spleen enlargement ( ) Bilateral symmetry of vocal fremitus ( ) Bronchial breath sounds ( ) Vesicular & bronchovesicular breath sounds ( ) Symmetric, full, & thrusting pulse ( ) No sound ( ) Not visible ( ) Symmetric ( ) Flat ( ) rounded (convex) ( ) scaphoid (concave) ( ) no enlargements of liver or spleen ( ) Symmetric movements caused by respiration ( ) Audible bowel sounds ( ) no bruits or friction rubs ( ) Not tender

( ) asymmetric pulse ( ) weak pulse ( ) audible sounds ( ) visible ( ) asymmetric ( ) lesions ( ) enlarged liver or spleen ( ) limited movements because of pain ( ) bruit, friction rub ( ) tenderness ( ) masses ( ) atrophy ( ) hypertrophy ( ) asymmetric ( ) tremor ( ) atonic (lacking tone) ( ) flaccidity ( ) spasticity ( ) 25% or less of normal strength ( ) swollen ( ) tender ( ) nodules ( ) limited ROM Normal NORMAL

2. Abdominal movements 3. Auscultation, vascular sounds, friction rubs 4. Palpation Upper & lower

extremities 1. Inspection (muscles) 2. Fasciculation & tremor 3. Palpation (at rest) 4. Palpation (contracted) 5. Muscle strength tests 6. Inspection & palpation of joints

( ) no masses ( ) Equal size on both sides of the body ( ) No fasciculation or tremor ( ) Normally firm ( ) Smooth coordinated movements ( ) Equal strength on each body side ( ) No swelling ( ) no tenderness ( ) no nodules ( ) Smooth movement

Limited range of motion.

Joint movements