Body Part Actual Finding Normal Finding Clinical

Examined Significance
THORAX &
LUNGS
Posterior  Normal chest  Anteroposterior to
Thorax shape with no the transverse Assessment of
I: shape & deformities and diameter in ratio the symmetry
spine vertically 1:2. and shape of the
symmetry from
aligned.  Chest symmetric. spine is to
posterior-lateral
 Sipinal column is determine any
views; spinal abnormalities
straight, right and
alignment for left shoulders, and that will indicate
deformities hips are at the deformities such
same heights. as barrel chest,
kyphosis, or
scoliosis.

Assessment is
 Equal temp from performed to
both sides of the
 Skin is intact with determine any
body. No use of abnormalities
Pa: temperature, uniform
accessory associated with
temperature.
bulges, muscle, neck, the breathing
 Chest wall intact,
tenderness, shoulder, and and to
no tenderness, no
abnormal abdominal muscle investigate the
masses.
movements, during respiration lung size and to
respiratory  No tenderness is palpate for good
excursion, appreciated upon ventilation of the
vocal fremitus palpation of the lungs.
chest wall.

 Full and symmetric

To assess for
 The patient does chest expansion.
any trouble
Pe: for symmetry not exhibit signs  Bilateral symmetry
of resonance; of tactile fremitus. associated
of respiratory distr breathing and
diaphragmatic ess.  Excurison is 3:5
excursion breathing
cm bilaterally in
pattern. To
women, and 5:6
determine the
cm in men.
size of the
diaphragm and
 Regular  Quit rythmic, and
its normal
A: breath sounds respiratory movement.
effortless

John Lloyd B. Agasang

BSN 2-3
 rhythm. Quit and respirations. Auscultation of
unlabored the breath sound
respiration. to rule out any
respiratory
disorder.

 Coastal angle is
 Normal breathing less than 90
Anterior Thorax pattern with no degrees and the
I: breathing tenderness upon ribs insert into the
pattern, coastal palpation of spine at
and costovertebral approximately a 45
costovertebral with its position in angle.
angle the right area and
angle.  Full symmetric
excursion, thumbs
normally seperate
3:5 cm.
 Equal and  Should sound with
moderate resonant and full
Pa: respiratory vibration during sound.
excursion, speech
tactile fremitus  Bronchial and
tubular breath
sounds.
 Tracheal is very
load and high  Broncho vesicular
Pe: symmetry of pitched sounds. breath sounds.
resonance duration of
A: breath sounds inspiration and
expiration is
equal. Bronchial
is loud and
medium pitched
sound and the
vesicular is low
pitched as
examined.

John Lloyd B. Agasang

BSN 2-3
Heart  Normal heart  The precordium is A thrill is a
I: precordium for sound with S1 symmetrical. palpable murmur
pulsations & sounding with low  S1 should be whereas a heave
lifts or heaves louder at the apex, is a sign of left
pitched sound and
lower pitch, and ventricular
A: heart sounds clearly heard from
longer than S2. hypertrophy. A
(S1, S2, etc.) the apex, and the thrill feels like a
 S2 should be
S2 heard loudly at vibration and a
louder at the base,
the base with no higher pitch and heave feels like
murmurs. shorter than S1. an abnormally
large beating of
the heart. Feel
for these all over
the precordium
Central Vessels:  No bruit sound  A pulse is normally
Carotid Arteries heard during heard, but without
P: volume, quality auscultation and sounds during
A: bruit with clear and systole.
Jugular Veins visible and normal  The normal mean
The internal
I: distention alignment of jugular venous
carotid arteries
pressure,
jugular vein are of vital
determined as the
without skin importance for
vertical distance
discoloration oxygenated
above the midpoint
around the skin on blood supply to
of the right atrium,
veins. the brain, and so
is 6 to 8 cm H2O
they are of major
importance in
clinical
Peripheral  Upon inspection, evaluation. They
Vessels skin is pink and  Absence of are susceptible
I: presence or normal, no signs swelling of the to
appearance of of swelling veins that atherosclerosis,
superficial indication indicate which can cause
veins, signs of phlebitis. stenosis and
phlebitis. Skin
 In a limb with a embolization of
phlebitis color able to normal
*Buerger’s Test return back to plaque distally
circulation the towards the
*Capillary Refill normal skin color toes and sole of brain.
within 2 seconds the foot, stay
indicating normal pink, even The peripheral
capillary refill. when the limb is vascular
And still is normal raised by 90 examination
upon doing the degrees. provides
buerger’s test with  The normal valuable
skin being able to CRT is <2 information on
seconds; a general health
retain its normal
CRT of >2 status and can
pinkish color even seconds help to determine
when raised to 90 suggests poor the status of the

John Lloyd B. Agasang

BSN 2-3
 degrees high. peripheral arteries and
perfusion and veins.
may be an early
sign of shock.
Assessment of
 Upon inspection,
 Bilateral breasts the breast and
breast is equal in axilla is to gather
are
Breast & Axillae size and is symmetrical, objective
I: breast for size, symmetrical. No nontender, no information about
symmetry, skin discoloration suspicious the condition of
contour or appeared during masses, skin or the body part.
shape, inspection and ni nipple changes This is to
discoloration, swelling or or determine any
retraction, tenderness during lymphadenopat palpable mass,
hypervascularit palpation. Nothing hy. skin discoloration
y, swelling, mass felt in the indicating
edema underlying
breast and no
serious health
: areola for size, lesion seen and risks.
shape, texture normal
symmetry, during inspection
color, surface of the areola.
characteristics,  Nipple is in the
masses, lesions center position,
: nipples for color is good no
size, shape, lesion and dry and
position, color, good upon
discharge, inspection and
lesion palpation.
 Upon palpation of
the lymph nodes,
P: lymph nodes, breast, areola, and
breast, areola nipples there is no
& nipples for tenderness felt and
tenderness, no pain felt by the
masses, patient during
nodules, assessment. No
discharge masses and
nodules and
without any
discharge and all
normal upon
examination.

John Lloyd B. Agasang

BSN 2-3