Deanielle Pathrise F.

Vergara

Questions
1.Gather all equipment needed for a head to toe
exam.
2.Prepare client by explaining what you will be
doing.
General Survey
1.Observe appearance.
2.Assess vital signs.
3.Take body measurements.
4.Calculate ideal body weight, body mass index,
waist to hip ratio, mid-arm muscle area and
circumference.
5.Test vision.
Mental Status Examination
1. Observe LOC.
2. Observe posture and body movements.
3. Observe facial expressions.
4. Observe speech.
5. Observe mood, feelings, and expressions
6. Observe thought processes and perceptions.
7. Assess cognitive abilities.
8. Give client a specimen cup if sample is needed,
and ask the client to sit on examination table.
Skin
1. Throughout the examination, assess skin for
color variations, texture, temperature, turgor,
edema, and lesions.
2. Teach skin self-examination.
Head and face
1. Inspect and palpate the head.
Findings
Equipments are complete, sterile and functional.
Patient understood and agreed with the
procedure.
The patient is a healthy adult male with brown
skin, and fit physique.
Vital signs are normal. Patient’s BP is 120/80, RR
is 20, PR is 80 and temp is 36.8°C, and there is no
sign of pain.
180cm. 60 kg. Waist is 40 cm. Hip is 42cm. MAC is
18.5”.
BMI is 27.0, WHR is 0.89, MAC is 29.0
Poor eyesight with myopia.
Client is alert and oriented to person, place, time
and events.
Client is relaxed with shoulders erect when
standing and sitting.
Client maintains eye contact, smiles, and frowns
appropriately.
Speech is moderate tone clear and with
appropriate pace.
Mood and expressions are appropriate on
specific scenarios.
Thought process and perceptions of client is
normal.
Cognitive abilities are normal.
Client had executed the procedure properly with
no signs of abnormality.
There were no skin discoloration, texture is fairly
smooth, temperature is evenly distributed,
turgidity is normal, with no edema or lesions.
The patient properly understood and
demonstrated self examination.
No lesions or swelling and abnormalities were
found.
2. Note consistency, distribution, color of hair.
3. Observe face for symmetry, features,
expressions, condition of skin.
4. Have a client smile, frown, show teeth, blow
out cheeks, raise eyebrows, and tightly close eyes
(CN V).
5. Test sensations of forehead, cheeks, and chin.
6. Palpate temporal arteries for elasticity and
tenderness.
7. Palpate Temporomandibular joint.
Eyes
1. Assess visual function.
2. Inspect external eye.
3. Test papillary reaction to light.
4. Test accommodation of pupils.
5. Assess corneal reflex.
6. Use ophthalmoscope to inspect interior eye.
Ears
1. Inspect auricle, tragus, and lobule.
2. Palpate auricle and mastoid process.
3. Use otoscope to inspect auditory canal.
4. Use otoscope to inspect tympanic membrane.
5. Test hearing.
Nose and Sinuses
1. Inspect external nose.
2. Palpate external nose for tenderness.
3. Check patency of airflow through nostrils.
4. Occlude each nostril and ask client to smell for
soap, coffee, or vanilla.
5. Use otoscope to inspect internal nose.
6. Transilluminate maxillary sinuses.
Mouth and Throat
1. Put on gloves.
2. Inspect lips.
3. Inspect teeth.
4. Check gums and buccal mucosa.
5. Inspect hard and soft palates.
Hair strands are evenly distributed, hair color is
black and smooth.
Facial configurations are symmetric, no swelling,
lesions or any abnormalities.
The patient properly executed every
demonstration indicating normal signs.
Patient’s sensation were normal.
Temporal are non tender.
No inflammation were found.
Patient has problems visualizing distant
objectives without corrective lenses.
There are no abnormalities such as discoloration,
inflammation, or lesions.
Pupil constricted on both eyes of the patient.
No sudden or jerky movements where found
Cornea properly constricted and dilated on both
eyes.
Interior eyes are normal without opacity.
Both ear structures were normal, without any
lesions, discoloration or inflammation.
Both parts were non tender normal in size.
Auditory canal are normal with minimal cerumen.
Tympanic membrane is in pearly white condition.
Hearing of the patient were normal.
There were no visible lesions, swelling or trauma.
Nose were non tender.
Normal breathing were seen with normal
patency.
The patient accurately smelled and identified the
scents.
Inner nose never indicated bleeding or swelling.
There were no fluid or masses visible.
Gloves were sterile.
Lips were moist and pinkish color.
Patient has enough number of teeth without
wisdom tooth but have occlusions on central
incisors.
Gums and mucosa are evenly moist, pinkish in
color, and no swelling were found.
Palates are symmetrical, and moves up normally.
6. Observe uvula.
7. Assess for gag reflex.
8. Inspect tonsils.
9. Inspect and palpate tongue.
10. Assess tongue strength (CN IX and X).
11. Check taste sensation (CN VII and IX).
Neck
1. Inspect appearance of neck.
2. Test ROM of neck.
3. Palpate preauricular, postauricular, occipital,
tonsillar, submandibular, and submental nodes.
4. Palpate trachea.
5. Palpate thyroid gland.
6. If enlarged, auscultate thyroid gland for bruits.
7. Palpate and auscultate carotid arteries.
Arms, Hands, and Fingers
1. Inspect upper extremities.
2. Test shoulder shrug and ability to turn head
against resistance (CN XI spinal)
3. Palpate arms.
4. Assess epitrochlear lymph nodes.
5. Test ROM of elbows.
6. Palpate brachial pulse.
7. Palpate ulnar and radial pulses.
8. Test ROM of wrist.
9. Inspect and palpate palms of hands.
10. Test ROM of fingers.
11. Use reflex hammer to test biceps, triceps, and
brachioradialis reflexes.
12. Test rapid alternating movements of hands.
13. Test sensation in arms, hands, and fingers.
Patient has mono-uvula without swelling.
Patient experiences gag reflex when uvula or
throat is agitated which normal.
Tonsils are graded with a 1, which are normal in
size behind the palate with no enlargement.
Tongue is normal in length, are pink and no hair
were found. Fissure is visible but not very deep.
The tongue was able to push the depressor
without struggle.
Patient could identify the tastes.
No veins were protruded. Neck was not red or
swelling.
The patient properly executed a proper
movement without struggles.
These were non tender and non palpable
indicating no infection.
Trachea is not enlarged and is inmidline.
Thyroid glands are not swollen.
No enlargement as well as bruit sounds..
Arteries were pulsating when simultaneously
palpated.
Arms are perpendicular and congruent with the
body.
The patient can properly shrug and easily turn
head.
Arms are not swollen and do not have any
lesions.
No inflammation and lesions were found.
The patient properly executed the positions
without struggle.
The brachial pulse has a normal pulse rate.
The ulnar and radial pulses had no signs of
abnormality.
The patient properly executed the motion
without struggles.
Hands were smooth and moist with no swelling,
tenderness, discoloration, or any lesions.
Patient’s fingers properly executed the
demonstration smoothly.
Normal reflex were noted.
The pace of the alternation of the was normal.
The patient’s arms, hands were and fingers can
determine different sensations such as pain, in
necessary conditions.
Posterior and Lateral chest
1. Ask the client to continue sitting with arms at
sides and stand behind the client. Untie gown to
expose posterior chest.
2. Inspect scapulae and chest wall.
3. Note the use of accessory muscles when
breathing.
4. Palpate the chest.
5. Evaluate chest expansion at T9 or T10.
6. Percuss at posterior intercostal spaces.
7. Determine diaphragmatic excursion.
8. Auscultate posterior chest.
9. Test for two-point discrimination on back.
10. Auscultate apex and left sternal border of
heart during exhalation.
Anterior Chest
1. Inspect chest.
2. Note quality and pattern of respirations.
3. Observe intercostal spaces.
4. Palpate anterior chest.
5. Percuss anterior chest.
6. Auscultate anterior chest.
7. Test skin mobility and turgor.
8. Ask client to fold gown to waist and sit with
arms hanging freely.
Male Breasts
1. Inspect breast tissue.
2. Palpate breast tissue and axillae.
3. Assist client to supine position with the head
elevated to 30 to 45 degrees. Stand on client’s
right side.
Neck
1. Evaluate jugular venous pressure.
2. Assist client to supine position.
Heart
1. Inspect and palpate for apical impulse.
The client properly executed the procedure.
The patient has a chest ratio of 1:2, without
protrusion.
There were no aggressive shrugging found when
breathing.
Patient’s chest does not have any lesions nor
swelling.
Expansion were normal.
There were no signs of tympany over the area.
No dullness were percussed. Diaphragm normally
expanded.
There were no adventitious sounds heard.
Posterior thorax were normal in accordance with
the two point discrimination.
No irregular rhythm were found.
There are no protrusion or swelling, nor
abnormal sternal retraction.
Respirations are relaxed, effortless, and quiet.
No retractions or protrusions were visible.
No tenderness or pain, masses, and crepitus was
palpated over the lung area.
Resonance were elicited over the percussion.
Bronchial sound were found and not adventitious
sounds.
The patient has normal mobility.
The patient properly executed the procedure.
Breast were normal. There no swelling or lesions.
No swelling, nodules or ulceration were found.
The procedure was properly executed and no
abnormalities or difficulties found.
Jugular vein isn’t visible, swollen or protruded, or
abnormally pulsating.
Client properly executed procedure without
difficulty.
Pulse are not visible, but is palpated over the
mitral area.
2. Palpate the apex, left sternal border, and base No pulse or vibrations were palpated in the
of the heart. areas.
3. Auscultate over aortic area, pulmonic area, Erb A sound is heard in each area but loudest on the
point, tricuspid area, and apex. apex area. Normal heart beat were elicited.
4. Auscultate apex of heart as client lays on left There were no murmurs heard or abnormal
side. sound heard.
Abdomen
1. Cover chest with gown and arrange draping to The procedure was properly executed without
expose abdomen. difficulty.
2. Inspect abdomen. Abdomen is symmetric, umbilicus is in midline,
no lesions were found, and it is not protruded.
3. Auscultate abdomen. Bruits were not heard, there were no venous
hum, no hyperactive or hypoactive sounds heard.
4. Percuss abdomen. No accentuated tympany or hyperresonance, and
friction rub heard.
5. Palpate abdomen. No tenderness elicited, nontender and not hard.
Legs, Feet, and Toes
1. Observe muscles. There is no swelling, lesions or muscle dystrophy.
2. Note hair distribution. Venous hair were found in some parts of body.
3. Palpate joints of hips and test ROM. No dislocation or fracture of hip. Patient properly
executed the procedure without difficulty.
4. Palpate legs and feet. No pain, heat, swelling, or nodules, were found.
5. Palpate knees. Knees are nontender, there is no nodules or
swelling, bulge or fluid found and clicking.
6. Palpate ankles. There’s no sprain or abrupt ligaments seen.
7. Assess capillary refill. The skin refill was normal.
8. Test sensations (dull and sharp), two-point Every procedure was done effortlessly indicating
discrimination, reflexes, position sense, and normal functioning.
vibratory sensation.
9. Perform heel-to-shin test. Patient properly executed the procedure without
struggle.
10. Perform any special tests as warranted. Patient is normal so there were no need of
proceeding an exam.
11. Secure gown and assist client to standing Patient properly executed the procedure without
position. difficulty.
Musculoskeletal and Neurologic Systems
1. Observe for spinal curvatures and check for The patient does not have scoliosis.
scoliosis.
2. Observe gait. The patient has a normal manner of walking.
3. Observe tandem walk. The patient’s pace of walking is normal.
4. Observe hopping on each leg. The patient can execute the procedure, with not
too much difficulty.
5. Perform Romberg test. The patient did not fall so he is negative for
Romberg’s tests.
6. Perform finger-to-nose test. The patient properly executed the procedure
without signs of abnormality.
Male Genitalia
1. Sit on a stool and have the client stand and
face you with gown raised. Apply.
2.Inspect penis.
3.Palpate for urethral discharge.
4.Inspect for scrotum.
5.Palpate for both testis and epididymis.
6.Transilluminate scrotal contents.
7.Inspect for bulges in inguinal and femoral areas.
8.Palpate for scrotal hernia.
9.Palpate for inguinal hernia.
10. Teach testicular self examination.
11. Inspect perineal area.
12. Inspect sacroccygeal area.
13. Inspect for bulges or lesions as Valsalva
maneuver is performed.
Rectal
1.Ask the client to remain standing and to bend
over the exam table. Change gloves.
2.Palpate anus.
3.Palpate external sphincter.
4.Palpate rectum.
5.Palpate peritoneal cavity.
6.Palpate prostate.
7.Inspect stool.
The patient properly executed the procedure.
Penis is normal in size without lesions.
There were no discharge as palpation was done.
The size is normal, hangs low in standing position.
They are uniform in size, smooth and nontender.
They did not contain masses of serous fluid.
There were no bulges or signs of hernia.
Bulge or mass were not palpated.
There were no bulge or mass palpated.
The patient understood the procedure.
Area is hairless, moist and tightly closed.
Area is smooth and is free from swelling or hair
No signs of rectal prolapse were found.
The client properly executed the procedure.
Client’s sphincter relaxes, permitting entry.
Fingers did enter the anus.
The rectum was smooth, nontender, and no
nodules were found.
The areas was smooth and nontender with no
signs of rectal shelf.
Are nontender and rubbery, not swollen, and
does not elicit any prostatitis.
Stool is brown, semi sold and free of blood and
free from rectal cancer symptoms.