SKIN, NAILS AND HAIR

SKULL, FACE, EYES AND EARS

NOSE, MOUTH AND NECK
THORAX AND LUNGS

HAIR AND HEAD

 No dandruff or lice
 there are no lesions or any scars on the scalp
 the head size seems to be normal
 so im gonna palpate your head, im just gonna touch it and tell me if there’s
any pain, okay? (do you feel any pain? How about here?)
 PATIENT HEAD SIZE IS NORMAL, HAIR IS NORMAL AND IT IS SMOOTH TO
THE TOUCH.
 NO LESIONS, NO DANDRUFFS OR ANY LICE
FACE
So now we’re gonna proceed to assessing the face of the patient
 So, the PALPEBRAL FEATURE seems to be symmetrical and normal (so
ma’am can you smile for me?)
 So, the presence of NASALOBIAL FOLDS is present and symmetrical om
both the left and the right side
 Im gonna proceed to inspecting or assessing your eyebrows
 It seems to be symmetrical on the left and the right side (mam can I touch
it)
 So, the distribution of the hair seems to be even and normal on the left and
the right side
 So, the patients’ eyelashes are evenly distributed both on the left and the
right side, both are symmetrical (so mam can I just touch your face)
EYES
 So the patient’s eyelids seem to be symmetrical also both on the left and
right side
  So mam could you close your eyes tightly and open them up for me
 Patients has no trouble opening and closing the eye
 The eyelids are covering the part of the sclera which is normal
*Continue assess the patients’ palpebral conjunctiva
 Mam could you look down for me
 So im gonna pull on your lashes a bit okay
 So, there’s no swelling, no presence of foreign objects or any pain felt by
the patient as I check the palpebral conjunctiva
 Now im going to proceed in palpating the lacrimal glands of the patient
(mom is it okay if I your face)
 So there seemed to be no swelling and everything is normal with the
lacrimal gland
 Proceed to touching the nasolacrimal gland (do you feel any pain as I touch
it?)
 Patient feels no pain and there is no presence of swelling
 Assessing the conjunctiva (touch face and look up) Pinkish in color, there
seem to be no foreign bodies or any type of swelling or infection (patient
conjunctiva is normal)
 Now for the sclera and the cornea looks perfectly normal both on the left
and the right side and there are no abnormalities with the patient’s cornea
both the left and the right side (SO SCLERA AND CORNEA ARE NORMAL)
 ASSESS THE CORNEAL SENSITIVITY REFLEX TEST. (MAKE A WHISK OF
COTTON APPROACH FROM THE SIDE OF THE EYES TOUCH THE CORNEA OF
THE CLIENT WITH THE WHISK OF COTTON) CLIENT BLINKS
BILATERALLYWHEN THE CORNEA IS TOUCHED, INDICATING THAT THE
TRIGEMINAL (5TH CRANIAL NERVE) IS INTACT.
 ASSESSES SIX OCULAR MOVEMENT (DRAW A BIG H ) BOTH EYES
COORDINATED, MOVE IN UNISON, WITH PARALLEL ALIGNMENT

 PROCEED TO ASSESSING THE PATINTS IRIS – SO THE PATIENT’S IRIS IS DARK

BROWN IN COLOR. BOTH IRIS ARE THE SAME SIZE SO THE NORMAL ISIRS
SIZE SHOULD BE 10.2 MILLIMETERS TO 13 MILLIMETERS
  PROCEED TO CHECKING THE CONSTRUCTION OF THE PATIENT’S PUPILS SO
I’VE DIMMED THE LIGHT (SO MAM IM GONNA CHECK YOUR EYES AGAIN IM
GONNA SHINE A LIGHT ON YOUR EYE IS IT OKAY WITH YOU?
 SO, I WANT YOU TO LOOK AT THAT OBJECT RIGHT THERE, SO JUST LOOK AT
THAT FOR THE MOMENT, IM GONNA START OKAY
 SO, BOTH THE LEFT AND THE RIGHT PUPILS ARE CONSTRICTING AS IT
SHOULD AND IT IS NORMAL
 WE’RE GONNA CHECK FOR THE ACCOMODATION OF THE PUPILS (LIGHT
AGAIN)
 BOTH PUPILS ARE STILL CONSTRICTING BOTH RIGHT AND LEFT, BOTH ARE
ALSO RESPONSIVE TO THE LIGHT
 I WANT YOU TO LOOK AT MY FINGER AS I SHINE A LIGHT ON YOUR EYE
 SO, BOTH PUPILS THE L&R ARE STILL CONSTRICTING AND REACTIVE TO THE
LIGHT SO IT IS NORMAL, IT HAS ACCOMODATION AND IT IS RESPONSIVE TO
LIGHT

 PERIPHERAL VISION (I WANT YOU TO COVER YOU ONE EYE USING YOUR
HAND AND IM GOING TO WIGGLE MY FINGIRS THEN TELL ME IF YOU CAN
RECOGNIZE IT OKAY.
 SO PATIENT PERIPHERAL VISION SEEMS TO BE NORMAL, PATIENT CAN
ALSO RECOGNIZE THE WIGGLING OF THE FINGERS AND THERE IS NO ANY
TROUBLE.
 ASSESSES VISUAL ACUITY. ( USE NEWSPRINT ( NEWSPAPER/BOOK OR
MAGAZINE, PLACED T LEAST 12 -14 INCHES AWAY FROM THE CLIENT ) ABLE
TO READ NEWSPRINT .

EARS
 IM JUST GONNA SEE IF YOUR EARS IS LEVELED TO THE SIDES OF YOUR EYES
(SO THE PATIENTS PIN OF THE EAR IS ALMOST AT LEVEL OF THE PATIENTS
EYE
 PALPATE FOR THE CARTILAGE AND MASTOID PROCESS (THERE SEEMED TO
BE NO SWELLING WITH THE CARTILAGE) AND NOW TO THE MASTIOD
 PROCESS (DO YOU FEEL ANY PAIN? TENDERNESS?) THERE ARE NO
SWELLING AND NO MASSES (SO CARTILAGE AND MASTOID PROCESS IS
NORMAL)
 NOW ASSESS THE PATIENTS EAR CANAL AND TYMPANIC MEMBRANE
(PATIENTS EAR CANAL IS SAME WITH THE COLOR OF THE EAR AND THERE
ARE NO PRESENCE OF FOREIGN BODIES, THERE IS CERUMEN OR WAX
WHICH IS TOTALLY NORMAL FOR THE PATIENT) PROCEED TO THE OTHER
SIDE
 WHISPER TEST _IN HEARING ACUITY THE PATIENT IS ABLE TO REPEAT THE
WORDS I SAY, AND THERE SEEM TO BE NO TROUBLE IN HEARING OF THE
PATIENT EARS
 IN CASE ABNORMALITY IN HEARING ACUITY IS DETECTED, PERFORM :
A) WEBER TEST: ASSESS BONE CONDUCTION BY EXAMINING
THE LATERALIZATION (SIDEWARD TRANSMISSION) OF SOUNDS.
B) RINNE’S TEST : USED TO ASSES CONDUCTIVE HEARING LOSS.
IT COMPARES PERCEPTION OF SOUNDS TRANSMITTED BY AIR CONDUCTION
TO THOSE TRANSMITTED BY BONE CONDUCTION THROUGH THE MASTOID.

NOSE
 PATIENTS NOSE IS IN THE MIFFLE OF THE FACE OR MIDLINE; THERE SEEM
TO BE NO DEVIATIONS LEFT OR THE RIGHT. SEPTUM IS NORMAL, BOTH
NOSTRILS ARE NORMAL
 WE’RE GOING TO OCCLUDE ONE SIDE OF YOUR NOSTRIL (DID YOU HAVE A
HARD TIME BREATHING?) PATIENTS CAN BREATHE PERFECTLY NORMAL
EVEN IF ONE SIDE IS OCCLUDED SO THERE IS NO OBSTRUCTION IN THE
NOSE
 PALPATE THE EXTERNAL NOSTRILS OR NAIR
 INTERNAL NAIRS (IM JUST GONNA PLACE MY HAND ON YOUR FOREHEAD
AND THEN TILT IT BACK A BIT) SO PATIENT NASAL MOCUSA IS PINKISH IN
COLOR, THERE ARE NO SWELLING, NO FOREIGN BODIES, THERE ARE NO
PRESENCE OF EXUDATES, THERE IS ALSO NO SEPTUM PERFORATION
  PATIENTS SINUSES THE MAXILLARY AND THE FRONTAL (THERE IS NO
SWELLING AND PAIN AS PER THE PATIENT)
MOUTH
 MOUTH & LIPS
o PATIENTS LIPS ARE SYMMETRICAL BOTH L&R, AND THERE IS NO
LESIONS, NO BLEEDING, NO EDEMA OR ANY PROBLEM WITH THE
LIPS
o PATIENTS LIPS ARE SOFT AND SMOOTH
 TEETH
o COULD YOU SMILE, OPEN YOUR MOUTH PLEASE, (SO THERE ARE __
TEETH WHICH IS NORMAL FOR A 14-YEAR-OLD GIRL LIKE HER, THE
DOMINANT COLOR OF THE TEETH IS WHITE AND THERE IS NO
MALOCCLUSION
o STICK OUT YOUR TONGUE (THERE SEEM TO BE NO SWELLING, NO
PAIN AND NO PRESENCE OF EXUDATE AND THE TONGUE IS IN THE
MIDLINE IS IT NOT DEVIATING TO THE LEFT OR THE RIGHT SIDE
 UVULA along with it of course is the soft palate (please say ah for me, I
want you to say a like really long)
o PATIENTS UVULA IS VIBRATING OR MOVING AS SHE SAYS AH WHICH
IS TOTALLY NORMAL AND IT IS PINKISH IN COLOR, THE TONSILS ARE
PERFECTLY NORMAL IT IS AROUND 2.5 CENTIMETERS, THERE IS NO
SWELLING ALSO ON THE UVULA OR THE TONSILS
NECK
 BEND YOUR NECK TO YOUR SHOULDER BOTH THE L&R COULD YOU DO IT
FOR ME? (PAIN??)
o PATIENT COULD DO IT EFFORTLESSLY AND W NO PAIN
o BEND NECK FORWARD AND BACKWARD (PATIENT HAD NO TROUBLE
DOING WHAT I SAID SHE FELT NO PAIN. PATIENTS NECK IS MOVABLE
AND THERE ARE NO PROBLEMS
o PATIENTS TRACHEA IS IN MIDLINE POSITION, NOT DEVIATING TO THE
LEFT NOR TO THE RIGHT. THERE IS NO VISIBLE JUGULAR VEIN
DISTENSION, THERE IS ALSO NO PRESENCE OF THYROID LUMPS
 o PATIENTS NECK IS NORMAL A PER INSPECTION
o PROCEED IN PALPATING THE PATIENT’S THYROID AND IM GONNA DO
THE ANTERIOR APPROACH (FEELS NO PAIN)
o PALPATE IF SHE HAS AN ENLARGED THYROID, I WANT YOU TO TILT
YOUR HEAD OVER
o FEELS NO PAIN & NI ENLARGEMENT OF THE THYROID
o THYROID IS SMOOTH PLIABLE AND NON-TENDER
o LYMPH NODES (THERE SEEM TO BE NO SWELLING OF THE LUMPH
NODES AND THE PATIENT DID NOT COMPLAIN OF ANY TENDERNESS
OR PAIN
o NECK DESTENSION (TILT YOUR HEAD A LITTLE) AS U CAN SEE THERE
IS NO NECK DESTENSION (THERE IS NO PRESENCE OF THE NECK
DERTENSION)

 AFTER ASSESSING YOUR HEAD, EYES, SKIN, HAIR, FACE, EARS, MOUTH,
NOSE, TONGUE, THROAT AND NECK. ALL FINDINGS SEEM TO BE NORMAL,
NO COMPLAINTS OF ANY TENDERNESS AND NO ABNORMALITIES.