PHYSICAL ASSESSMENT

BODY PARTS

NORMAL FINDINGS

1. Head
a. Skull

b. Scalp

c. Hair

ACTUAL FINDINGS

INTERPRETATION

Proportional to the body

size,
round,
with
prominence in the frontal
area anteriorly in the
occipital are posteriorly
symmetrical in all planes,
gently curved.
White, clean, free from
masses, lumps and sores.

Head is symmetrical to the

body. Free from lesions and
swelling.

Normal

No lumps noted on the scalp,

tenderness not complained,
and no dandruff.

Normal

Black, evenly distributed

and covers the whole
scalp, thick, shiny and
free from split ends.
Oblong or oval or round
or square or heart shaped,
symmetrical,
facial
expression
that
is
dependent on the mood or
true feelings, smooth and
free from wrinkles (for
young adults), and no
involuntary
muscle
movements.

Hair is black with some gray

hairs, evenly distributed.
Oval, symmetrical, facial
expression that is dependent
on the mood or true feelings,
no
involuntary
muscle
movements.

Normal

Normal

d. Face

e. Eyes

Parallel or evenly placed,

symmetrical,
nonprotruding, with scant
amount of secretions, both
eyes bright and clear.

The eyes are symmetrical,

has normal accommodation
and pink conjunctiva, free
from swelling. Visual acuity
not assessed but patient do
not use eyeglasses. No
complaints of itchiness, free
of exudates, white sclera.

Normal

f. Eyebrows

Black, symmetrical, thick,

raise
and
lower
symmetrically,
evenly
distributed and parallel to

Black, symmetrical, thick,

raise
and
lower
symmetrically,
evenly
distributed and parallel to

Normal

each other.
h. Eyelashes

i. Eyelids and
Lacrimal
Apparatus

each other.

Color dependent on race,

Evenly distributed, Turned
outward.
Eyelids
Upper eyelids cover the
small portion of the iris,
cornea, and sclera when
eyes are open.
No
PTOSIS
noted.
(Drooping
of
upper
eyelids).
Meets completely when
eyes are closed.
Symmetrical.
Lacrimal Apparatus
Lacrimal
gland
is
normally non palpable.
No
tenderness
on
palpation.
No regurgitation from the
nasolacrimal duct.

j. Sclera

Black, Evenly distributed,

Turned outward.
Not assessed.

Not assessed.

Sclera is white in color

(anicteric sclera)
No
yellowish
discoloration
(icteric
sclera).
Some capillaries maybe
visible.

Not assessed.

no
the

Not assessed.

k. Cornea

There should be
irregularities
on
surface.

Looks smooth.

The cornea is clear or

transparent. The features
of the iris should be fully

Normal

visible through the cornea.

l. Anterior
Chamber and
Iris

There is a positive corneal

reflex.

The anterior chamber is

transparent.

No noted any visible

materials.

Color of the iris depends

on the persons race
(black, blue, brown or
green).

From the side view, the

iris should appear flat
and should not be
bulging forward. There
should be NO crescent
shadow casted on the
other
side
when
illuminated from one
side.

Pupillary size ranges

from 3 7 mm, and are
equal in size.

Equally round.

Constrict
briskly/sluggishly when
light is directed to the
eye, both directly and
consensual.

Pupils
dilate
when
looking at distant objects,
and
constrict
when

Not assessed.

m. Pupils
Not assessed.

looking at nearer objects.

If all of which are met, we
document the findings using
the notation PERRLA, pupils
equally round, reactive to
light, and accommodate.
n. Cranial Nerve
III, IV & VI
(Oculomotor,
Trochlear,
Abducens)

Normally, the client can

hold the position and there
should be no nystagmus.

Not assessed.

The ear lobes are bean

shaped, parallel, and
symmetrical.

The upper connection of

the ear lobe is parallel
with the outer canthus of
the eye.

The ear lobes are bean

shaped,
parallel,
and
symmetrical. The upper
connection of the ear lobe is
parallel with the outer
canthus of the eye. Skin is
same in color as in the
complexion. No lesions
noted on inspection.

Skin is same in color as in

the complexion.

No lesions
inspection.

The auricles are has a firm

cartilage on palpation.

The pinna recoils when

folded.

There is no pain or
tenderness
on
the
palpation of the auricles
and mastoid process.

The ear canal has

normally some cerumen

o. Ears

Normal

noted

on

of inspection.

p. Nose and
Paranasal
Sinuses

q. Cranial Nerve
I (olfactory
Nerve)

No discharges or lesions
noted at the ear canal.

On otoscopic examination
the tympanic membrane
appears flat, translucent
and pearly gray in color.
Normal

Nose in the midline

No Discharges.

No flaring nostril.

Both nares are patent.

No bone and cartilage

deviation
noted
on
palpation.

No tenderness noted on
palpation.

Nasal septum in the mid

line and not perforated.

The nasal mucosa is

pinkish to red in color.
(Increased
redness
turbinates are typical of
allergy).

No tenderness noted on
palpation of the paranasal
sinuses.
The
client
must
distinguish the odor of the
two different aromatic
substances on both nares.

Nose in the midline. No

discharges.

Not assessed.