BODY PART INSPECTION PALPATION PERCUSSION AUSCULTATION

1. HEAD AND NECK

HEAD Normal: rounded Abnormal: lack of Normal: Abnormal: Not Not Not Not
; smooth skull symmetry; Smooth; sebaceous applicable applicable applicable applicable
contour increased skull uniform cysts; local
size with more consistency; deformities
prominent nose no nodules form
and forehead; and masses trauma,
longer mandible masses,
nodules
- HAIR Normal: evenly Abnormal: Not applicable Not Not Not Not Not
distributed hair ; patches of hair applicable applicable applicable applicable applicable
thick hair; silky loss; very thin
resilient hair; no hair; brittle hair;
infection/infesta excessively oily
tions; variable or dry hair ;
flaking sores, lice,
nits and
ringworm
- SCALP Size varies; Extremely large Normal: No Bumpy or Not Not Not Not
symmetrical and or small. Scalp is tenderness soft applicable applicable applicable applicable
round shape; thick in nor masses on
acromegaly; palpation
large; acorn
shape in Paget
disease ;
asymmetrical
- FOREHEAD No discoloration, ;presence of no tenderness Presence of Not Not Not Not
lesions discoloration Tenderness applicable applicable applicable applicable
- FACE Symmetrical; Asymmetrical. Not applicable Not Not Not Not Not
symmetric facial Face is applicable applicable applicable applicable applicable
features ; asymmetrical
palpebral fissures with parotid
equal in size gland
enlargement or
Bell Palsy , mask
face in
Parkinsons
disease
- EYES No edema; no Presence of Not applicable Not Not Not Not Not
hollowness edema; applicable applicable applicable applicable applicable
hollowness
 BROWS Eyebrows are Loss of hair, Not applicable Not Not Not Not Not
symmetrically scaling of the applicable applicable applicable applicable applicable
aligned and has skin; unequal
equal alignment and
movements , hair movement of
is evenly eyebrow
distributed
 LASHES Equally Lashes turned Not applicable Not Not Not Not Not
distributed and is inward applicable applicable applicable applicable applicable
curled slightly
outward
 LIDS UPPER Approximately Rapid, Not applicable Not Not Not Not Not
15-20 involuntary monocular, applicable applicable applicable applicable applicable
blinks per absent or
minute; bilateral infrequent
blinking blinking
LOWER Shiny smooth Lower lids Not applicable Not Not Not Not Not
pink in color turned: applicable applicable applicable applicable applicable
outward/inward
 SCLERAE Sclerae is light Sclera with Not applicable Not Not Not Not Not
blue petechiae; applicable applicable applicable applicable applicable
marked jaundice
 CONJUNCTIVAE Bulbar- Bulbar- jaundiced Not applicable Not Not Not Not Not
transparent; sclera; applicable applicable applicable applicable applicable
capillaries excessively pa;e
sometimes sclera, reddened
evident; sclera sclera; lesions or
appears white nodule
Palpebral- shiny, Palpebral-
smooth , pink or extremely pale;
red extremely red;
nodules or other
lesions
 CORNEA Transparent, Opaque; surface Not applicable Not Not Not Not Not
shiny and not smooth applicable applicable applicable applicable applicable
smooth; details
 of the iris are
visible
 IRIS Round, flat; Irregular. Miosis
evenly colored is constricted;;
mydriasis;
inconsistent
color; cloudy;
opacities
 PUPIL Round with a fixed pupils;
regular border ; anisocoria;
equal in size cloudiness,
mydriasis,
miosis , bulging
of iris towards
the cornea
 MUSCLE Eye follows the Light reflections
FUNCTION movement of the noted at
objects direction different areas
on both eyes
occur with
deviation in
alignment of
eyes
 MUSCLE BALANCE Both eyes follows Jerky eye
the objects movements are
direction seen with inner
symmetrically ear disorders,
multiple
 VISUAL ACUITY There is normal Any letters
visual acuity missed on 20/20
20/20 OD and OS line or above.
Client reads chart
by leaning
forward, with
head tilted
 PERIPHERAL Normal visual With reduced
VISION field degrees and peripheral vision,
client sees my client does not
finger at the report seeing
 same time that I object at the
see it same time as the
examiner
NOSE Color is the same Asymmetric; Solid Unstable Sinuses are
with the face ; discharge form placement; no placement; not tender
symmetric and nares; localized nodules, nodules or on
straight; no areas of redness masses or masses percussion
discharge or or presence of pain reported present;
flaring skin lesion on palpation client
verbalizes
pain on
palpations
 FRONTAL SINUSES Red glow Nontender to Client Not tender Flat ; dull
transilluminates palpation no verbalizes upon tone
the frontal crepitus is pain or percussion elicited;
sinuses evident discomfort client
on palpation expresses
with pain on
allergies or percussio
sinus n
infection
 MAXILLARY SINUSES Red glow Nontender to Client Not tender Flat ; dull
transilluminates palpation no verbalizes upon tone
the maxillary crepitus is pain or percussion elicited;
sinuses evident discomfort client
on palpation expresses
with pain on
allergies or percussio
sinus n
infection
Mouth
 Lips Smooth, moist, Cyanotic; dry;
no lesions and no lesions present
swellings and is
color pink
 Gums Gums are pink, Pale, markedly
moist and reddened.
smooth
 Teeth 32 teeth present; Missing teeth ;
 color is pearly darkened brown
white and shiny; or chalky white
stable fixation, discoloration
smooth surfaces
and edges
 Tongue Moist, papillae Dry, nodules,
present, ulcers present;
symmetrical papillae or
appearance, fissures absent;
midline fissures asymmetrical
present
- Frenulum Midline,
Wharton’s ducts
are visible with
salivary flow
- Sublingual area Smooth; pink,
shiny, slightly
pale with visible
veins
 Hard palate Pale and firm Firm with
irregular
transverse rugae,
common
variation
 Soft palate Moist, smooth, Spongy texture
pink with symmetrical
elevation or
phonation
 Uvula Fleshy, solid,
hangs freely in
the midline, no
redness or
exudates from
uvula
 Tonsils Pink
symmetrically
aligned
Ears
 External Ears are equal in Skin is smooth
 size; the auricle is with no
aligned with the lesions,
corner of each tragus,
eye bilaterally. auricle, and
Color is the same mastoid
with the face process are
not tender
 Internal Small amount of
cerumen is the
only discharge
 Auditory acuity Vibrations are
heard equally in
both ears during
Weber’s test
Rinne test: air
conduction is
longer than bone
conduction
Neck
 Lymph nodes There are
swelling; no
tenderness
 Trachea Midline
 Thyroid gland Landmarks
are positions
midline
II. Thorax
Chest anterior
 Lung Respirations are No Resonance Bronchus:
relaxed, tenderness, is the bronchial
effortless and no pain is percussion sounds, V-
quiet 10-20 palpated over tone elicited vesicular
cycles/ minute the lung area over normal sound;
with lung tissue BV-
respirations bronchiov
esicular
sounds
 Heart Apical impulse is The apical 60-100 bpm
not visible impulse is
 palpated on
the mitral
area
Chest posterior
 Lungs Client does not Client reports Resonance Normal sounds
use accessory no is the are bronchial,
muscles to assist tenderness, percussion bronchiovesicula
breathing pain or tone elicited r and vesicular
unusual
sensations
 Diaphragmatic excursion Excursion is
equal bilaterally
and measure 3-
5cm
Abdomen Abdominal skin is Abdomen is Tympanic tone A series of
paler than the non-tender predominates intermitte
general skin tone and soft nt soft
clicks and
gurgles are
heard at a
rate of 5-
30/minute
 Liver Not palpable
 Spleen Spleen is not
palpable
 Kidney Kidneys are
not palpable
III. Extremities
Upper
 Muscle tone No rashes,
smooth
 Muscle strength Grip: patient is
able to resist
force
 Reflexes Hypoactive:
biceps, triceps
and
brachioradials
Lower
 Muscle tone Patient was able
to exert force
 Muscle strength Clent was able
to resist force
 Reflexes
 Gait, balance and Plantar reflex:
coordination hyperactive