SKILLS IN PHYSICAL ASSESSMENT

FATHER’S NAME: HENRY BACARRO

General Description:
Mr. Henry, who is 46 years old and head of the family, has brown complexion, black hair and has a mesomorph body type. He also works as farmer.

VITAL SIGNS
Temperature Respiratory Rate Pulse Rate Blood Pressure Height Weight
st
1 Visit
Date: October 15, 2021 36.4°C 16 breaths per minute 60 beats per minute 120/60 mmHg 162 cm 53 kg

2nd Visit
Date: October 30, 2021 36.6°C 16 breaths per minute 60 beats per minute 120/60 mmHg 162 cm 53 kg

3rd Visit
Date: November 20,2021 36.8°C 18 breaths per minute 60 beats per minute 120/70 mmHg 162 cm 55 kg

1. SKIN
AREA/FEATUR TECHNIQU NORMAL KEY ANALYSIS AND
E TO ASSESS E SKILLS FINDINGS FINDINGS INTERPRETATION
Color Inspection Inspect variations in skin color Color varies from light 1st Visit: The color of the skin The skin color and
under natural sunlight to ensure to ruddy pink or dark is brown. The distribution of distribution are normal.
accuracy findings. brown, depending on the color is equally in all around the
race. Color is uniform body.
except for sun exposed
areas or normally 2nd Visit:
lighted pigmented areas During the second visit The
(nail beds, palms, lips) skin is brown in tone. The color
in dark skinned people. is evenly distributed throughout
the body.

Lesions Inspection Note for color, size, and
anatomic location and
distribution.
Palpation
Palpate lesions with finger pads
for mobility and contour (flat,
raised, or depressed) and
consistency (soft or durable)
3rd visit:
The skin is brown in tone on the
third visit. The color is
distributed equally across the
entire body.
Freckles, skin tags in 1st Visit: The skin has no
elderly, and some types The skin is free form lesions, it abnormality or has no
of birthmarks and moles has 5 moles in the face, one presence of lesions,
are normal. normal size moles in the leg and nodules, stags. The
has no birthmarks. moles are normal in
size and has no
presence of birthmark.
2nd Visit:
The skin is clear of lesions,
with five moles on the face and
one normal-sized mole on the
leg. There are no birthmarks.

3rd visit:
The skin is free of lesions on
the third visit, with five moles
on the face and one normal-
sized mole on the leg. There are
no birthmarks on my body.
Moisture Inspection Note amount and distribution Moisture varies with 1st Visit: The skin is moisture, The texture and
and activity, body and smooth, and soft. The skin moisture of the skin is
Palpation environmental moisture distribution is normal. normal.
temperature, and
humidity in skin folds 2nd Visit: The skin is supple,
and the axillae. smooth, and hydrated. The
 moisture distribution on the
skin is normal.

3rd visit:
The skin is soft, smooth, and
nourished during the third visit.
The skin's moisture distribution
is normal.
Temperature Palpation Palpate with dorsum of hand Temperature should be 1st Visit: The temperature is Normal temperature.
noting for uniformity of warmth. uniform and within 36.4°C which is normal.
normal range.
2nd visit: The temperature is
36.6°C and still is normal.

3rd visit:
The temperature is 36.8°C and
still is normal

AREA/FEATUR NORMAL KEY ANALYSIS AND

E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Texture (quality, Palpation Palpate with finger pads in Texture is not uniform 1st Visit: The skin texture is The skin texture is soft.
thickness, different areas like the palms and soles normal/ The texture of the soles The texture of the soles
suppleness) are thicker than any and palms are slightly and the and palms are slightly
areas. Wrinkled and thickness of the soles and palms rough and the thickness
leathery skin in the are normal and the skin has no of the soles and palms
elderly results from the sign of breaking and it is are normal. There is no
normal aging. Process flexible. breakage in the skin
with decreased collagen, and the flexibility of
subcutaneous fats, and 2nd visit: the skin is normal.
sweat glands. The skin texture is normal, the
soles and palms have a slight
texture, the thickness of the

Mobility and Palpation Assess mobility and turgor to
turgor (elasticity) measure elasticity of skin to
determine the degree of
hydration.
Palpate dependent areas like
the sacrum, feet, and ankles
for mobility by applying
pressure with thumb for 5
seconds. Rate the degree of
edema (accumulation of fluid
in intercellular spaces) by
assessing depth of indention.
Edema may be described on a
scale as follows:
1. 0 = no pitting
2. 1+ = trace/mild
(2mm) pitting
3. 2+ = moderate
(4mm) pitting
4. 3+ = deep/severe
soles and palms is normal, and
the skin is pliable with no signs
of cracking.
3rd visit:
The skin texture is normal at the
third visit, the soles and palms
have a modest texture, the soles
and palms are normal thickness,
and the skin is malleable with
no evidence of cracking.
Absence of indention is 1st Visit: The skin mobility and The skin turgor is
dependent areas and the elasticity are normal, when normal. There is no
resilience of the skin doing the skin turgor test the sign of dehydration.
spring back to its skin is returning quickly. There
previous state after is no sign of edema.
being pinched.
2nd visit:
The skin's mobility and
suppleness are still normal, and
the skin responds swiftly to the
skin turgor test. There are no
visible signs of edema.
3rd visit:
The skin's mobility and
suppleness are still normal at
the third visit, and the skin
responds quickly to the skin
turgor test. There are no
indications of edema present.
 (6mm)
5. 4+ = very
deep/severe
(greater than
8mm)
Pinch a fold of skin on the
sternal area using forefinger
and note for the spread with
which it returns to place
(turgor).

2. HAIR
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Color and Inspect Assess for color and Color varies from black 1st Visit: The color of the hair is The color of the hair is
Distribution distribution of scalp hair, to pale blonde based on shiny black with brown with normal and it has white
eyebrows, eyelashes, and the amount of melanin slight white color mixture. The color because the
body surface. present. color of the eyebrow, and patient is getting older.
eyelashes are black. The The color distribution
distribution of color is normal. and hair distribution is
The hair distribution is equal. normal.

2nd visit:
On the second visit, the hair is a
lustrous black with brown
undertones and a hint of white.
The brows and eyelashes are
black in tone. The color
dispersion is normal. The hair is
distributed unevenly.

3rd visit:
 The hair is now a rich black
with brown undertones and a
tinge of white on the third visit.
The eyelashes and brows are
black in color. Color dispersion
is typical. The hair is spread
about evenly.
Texture and Palpation Assess for the skin’s texture Thin, straight, coarse, 1st Visit: The hair is thin and The hair distribution is
oiliness and oiliness with the use of thick, or curly. Hair is curly. The texture is smooth and normal. The texture and
palm. shiny and resilient a slight oily. oiliness of the hair are
normal.
nd
2 visit:
The hair is thin and frizzy
during the second visit. The
texture is very smooth with a
hint of oiliness.

3rd visit:
The hair is thin and frizzy on
the third visit. It has a silky
smooth texture with a hint of
oiliness.
infestation Inspection Assess for any presence of Free from any 1st Visit: The hair is free for any The patient hair is free
infestation by examining the infestation. infestation. for any infestation.
hair and scalp.
2nd visit:
The hair is clear of any
infestation on the second visit.

3rd visit:
The hair is free of any
infestation after the third
 appointment.

3. SCALP
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Scaliness and Inspection Part the hair repeatedly all The scalp should be 1st Visit: The scalp is shiny, The scalp is normal,
scars over the scalp and inspect for shiny and smooth smooth and has no presence of shiny and smooth.
scaliness and scars. without lesions, lumps, lesions, lumps or any masses. There is no presence
or masses. of skin lesion in the
2nd visit: scalp.
The scalp is glossy, smooth, and
free of lesions, lumps, or tumors
on the second visit.

3rd visit:
On the third visit, the scalp is
shiny and smooth, with no
lesions, lumps, or tumors.
Tenderness, Palpation Place finger pads on the scalp Absence of redness or 1st Visit: The scalp has no There is no tenderness,
lesions, lumps, at the front and palpate down scaliness. presence of scaliness, tenderness lesions and masses.
masses the midline and each side for and redness. The scalp is healthy.
tenderness, lesions, lumps, or
masses. 2nd visit:
On the second visit, there is no
scaliness, soreness, or redness on
the scalp.

3rd visit:
There is no scaliness, pain, or
redness on the scalp on the third
visit.
4. NAILS
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
TO ASSESS
Color, shape, and Inspection Inspect for color and shape Nail beds is highly 1st Visit: The shape of the nail is The nails shape,
texture vascular with a pink perfectly rounded and the color texture and color of
color in light skinned is pink color. The texture is the client are normal.
clients and longitudinal smooth. The firmness of the
streaks of brown or nailbed is normal. The nails are
black pigmentation in not clubbing or spooning.
dark skinned clients.
Palpation Palpate nailbed for firmness Angle between 2nd visit:
and texture fingernail and base is The shape of the nail is
about 160 degrees. flawlessly rounded on the second
visit, and the color is pink. The
nail bed is firm surface is silky smooth. The nail
bed is normal in terms of
hardness. The nails aren't
spooning or clubbing.

Capillary refill Palpation Press two or more nails
between thumb and index
finger and note the degree of
blanching and return to
normal color.
3rd visit:
On the third visit, the nail shape
is perfect and the color is pink. It
has a silky smooth finish. In
terms of hardness, the nail bed is
normal. There's no spooning or
clubbing going on with the nails.
When pressure is 1st Visit: The capillary refill is The capillary refill is
released from the nail, it normal because it returned in normal.
promptly returns to its pick color in a second.
normal color.
2nd visit:
 The capillary refill is normal on
the second visit because it
returned to pick color in a split
second.

3rd visit:
On the third visit. Because it
returned to choose color in a
quick moment, the capillary
refill is typical.
Lesions Inspection Inspect the tissue surrounding Tissue surrounding the 1st Visit: There has no presence The tissues surround
nails for lesions. nail is intact. of lesions that surrounding the the nails is normal and
nails. there are not inflamed
or swelling.
2nd visit:
On the second appointment, no
lesions that surround the nails
were present.

3rd visit:
On the third visit. There were no
lesions surrounding the nails.

5. SKULL
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Shape and Inspection Inspect skull for shape, Rounded, symmetrical, 1st Visit: The skull is round and The skull shape and
symmetry symmetry, size in proportion normocephalic, and symmetrical. size of the client is
to body and position. upright. normal.
2nd visit:
The skull is spherical and
symmetrical on the second visit.

Contour, Masses, Palpation Palpate with fingerpads
Depressions and beginning in frontal area and
Tenderness continuing over parietal,
temporal, and occipital areas
for contour, masses,
depressions, and tenderness.
3rd visit: On the third visit The
skull is symmetrical and
spherical in shape.
Smooth, non-tender, 1st Visit: There are no presence There are no abnormal
free of masses or of tenderness, lesions, and findings. The contour
depressions. masses. The skull is smooth. is normal.
2nd visit:
There is no pain, lesions, or
masses present on the second
visit. It has a smooth surface.

3rd visit:
On the third visit Tenderness,
lesions, or masses are not
present. The skull is slick.
6. FACE
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Facial features Inspection Inspect facial features for May be oval, round, or 1st Visit: The facial feature is There is no discomfort
expression, shape, and square. Symmetrical symmetrical, the placement of or limitations in the
symmetry of eyebrows, features and movement. the nose is right, and the shape movements of the
placement of nose, eyes, and of the face is oval. But there is facial features. The
ears. sign of aging process. face shape is normal.

2nd visit:
On the second visit, the facial
features are symmetrical, the
nose is properly placed, and the
face is oval in shape. However,
there are signs of aging.
 3rd visit:
On the third visit The facial
features are symmetrical, the
nose is properly placed, and the
face shape is oval. However,
there are signs of the aging
process.
Edema and Inspection Inspect for any presence of No edema and masses 1st Visit: There are no presence There is no abnormal
masses edema and masses of edema, masses and lesions. finding.
The color distribution of the skin
of the face normal is equal.

2nd visit:
Edema, masses, and lesions are
not seen on the second visit. The
usual color distribution of the
skin of the face is uniform.

3rd visit:
During the third visit There is no
edema, mass, or lesion. The
color distribution of the skin on
the face is normal.

7. EYES
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Visual Acuity Inspection Test visual acuity. Normal vision based on 1st Visit: The vision of client is The client has a
1. Position Snellen chart the Snellen chart is 20/20 20/40 and the client has a corrective lens need to
20 ft. in front of client. at the distance of 20 feet corrective lens. When the client be wear, so that the
 2. Remove corrective the normal eye can read wears the corrective lens, the client can read and see
lenses, if appropriate. the chart). vision is 20/35. the letter clearly. The
3. Instruct client to cover client has difficulty on
one eye and read lines 2nd visit: reading small
starting with top of On the second visit, the client's characters (letter and
chart from left to right. vision is 20/40 and he wears numbers) when the
4. Note the line where corrective lenses. The client's client wears her
client reads more than eyesight is 20/35 when wearing glasses. The client
half of the letters. the corrected lens. experiencing aging
5. Record results as a process that affecting
fraction sc (without 3rd visit: the visual acuity.
correction), 20/ During the third visit The client's
distance number, and vision is 20/40, and he wears
the number of the corrective lenses. When wearing
letters missed. the corrected lens, the client's
6. Repeat same steps for vision is 20/35.
the other eye.
7. If appropriate, repeat
steps with patient
wearing the corrective
device.
Inspection Test eye for extraocular Eye movement should 1st Visit: The client gaze is The client eye
muscle movements: be symmetrical as both symmetrical in both eyes movement is normal.
1. Place the client in eyes follow the direction because it can follow the object
sitting position. of the gaze and easily.
2. Instruct the client to converge on the held
hold head still. object as its moves 2nd visit:
3. Ask the client to toward the nose. The client's focus is symmetrical
follow an object with in both eyes on the second visit
eyes. because it can readily follow the
4. Move objects with 6 object.
fields of gaze.
 3rd visit:
During the third visit Because
the client's gaze can easily
follow the object, it is
symmetrical in both eyes.
***The 6 Fields of Gaze 1st Visit: The field of gaze of the The client eye
1. Conjugate left lateral patient is normal because it can movement in the six
gaze follow the object when I drag it field of gaze is
2. Left down and lateral on the 6 field of gaze. normal.
gaze
3. Right down and lateral 2nd visit:
gaze The field of gaze of the patient is
4. Conjugate right lateral normal because it can follow the
gaze object when I drag it on the 6
5. Right up and lateral field of gaze.
gaze
6. Left up and lateral 3rd visit: On the third visit The
5. Observe for parallel The upper eyelids cover patient's field of gaze is normal
eye movement. only the uppermost part because it can follow an object
6. Pause during upward of the iris and are free when I drag it on the 6 field of
and lateral gaze field from nystagmus gaze.
to detect in voluntary (involuntary rhythmical
rhythmic oscillation of oscillation of the eyes).
eyes. A few beats of
7. Note position of upper nystagmus with extreme
eyelid in relation to lateral gaze can be
the iris and eyelid bag normal.
as the client’s eye
move from up and
down.
8. Move object forward
to about 5 inches in
 front of the client’s
nose at the midline
and observe for
convergence, and
record result.
External Inspection Observe upper eyelid.
anatomical
structures Check eyes and eyelids for
inflammation, crusting,
edema or masses.
Inspect lacrimal glands and
sacs for swelling.
Upper eyelid should 1st Visit: The upper eyelid of The external structure
overlap iris. client is overlapping in the iris. of the eyes has no
presence of abnormal
Eyes and eyelids should The Eyes and eyelids are free findings.
be free from form inflammation, crusting,
inflammation, crusting, edema or any masses. The
edema or masses. external structure is normal and
smooths.
2nd visit:
On the second appointment, the
client's upper eyelid is
overlapping the iris.
Inflammation, crusting, edema,
and masses are absent from the
eyes and eyelids. Externally, the
structure is smooth and normal.
3rd visit: On the third visit The
upper eyelid of the client is
overlapping the iris.
The eyes and eyelids are free of
inflammation, crusting, edema,
and masses. The structure is
smooth and normal on the

Palpation Check for blocking of
nasolacrimal duct by pressing
against inner orbital rim of
lacrimal sac.
Inspect duct by palpating on
the lacrimal sac and observing
for regurgitation of fluid.
Inspection Inspect bulbar and palpebral
conjuctiva and sclera.
a. Instruct client to look
upward while
depressing lower lid
with thumb.
b. Inspect for color,
redness, swelling,
exudates, or foreign
bodies.
c. Inspect cornea, lenses,
pupil, iris, and anterior
chamber:
outside.
Lacrimal gland should 1st Visit: The lacrimal gland is The lacrimal gland of
not be palpable. cannot be palpated and it is not the client is not
inflamed. The tears are freely swelling. There is no
Tears flow freely from flow in the both eyes of the problem on the
the lacrimal gland over client. flowing of the eyes.
the cornea and
conjunctiva to the 2nd visit:
lacrimal duct. The lacrimal gland can no longer
be palpated and is not inflamed
on the second visit. In the client's
both eyes, tears are freely
flowing.
3rd visit:
On the third visit The lacrimal
gland is not inflamed and cannot
be palpated. The client's tears are
streaming freely from both eyes.
Bulbar is transparent 1st Visit: The bulbar, palpebral The bulbar, palpebral,
with small blood conjunctiva and sclera is normal. sclera and the pupil of
vessels. The sclera is color white with both eyes are normal.
Palpebral conjunctiva some blood vessels. The
covering the inside of palpebral is moist and has
the upper and lower normal color. The corneas are
eyelids is pink and shiny, moist and clear. The
moist. diameter of the pupil is normal
Sclera is white with and has black color. When I
some superficial blood move my penlight, the pupil is
vessels depending on responding normal
the race.
2nd visit:
1. Stand in front Corneas are moist, shiny The bulbar, palpebral
of the client. and clear. conjunctiva, and sclera are
2. Shine penlight Lenses are transparent. normal on the second visit. The
directly on Pupils are black, round sclera is white in hue and
cornea. and equal diameter, contains some blood veins. The
3. Move light ranging from 2-6mm. palpebral is moist, and the color
laterally and Entire iris should is normal. The corneas are clear,
view cornea illuminate when shining shiny, and moist. The pupil has a
from that light laterally too normal diameter and a black
angle; note nasally. color. The pupil responds
color, normally when I shift my
discharge, and penlight.
lesions.
4. Look at pupil 3rd visit:
and note size On the third visit Normal bulbar,
and shape. palpebral conjunctiva, and
5. Shine penlight sclera. The sclera is white in
directly on color and contains blood vessels.
pupils to assess The palpebral is moist and the
lens and color. color is normal. The corneas are
6. Look at iris for gleaming, moist, and crystal
size, and clear. The pupil diameter is
ability of normal and the color is black.
pupils to react The pupil responds normally
to light. when I move my penlight.
7. Shine a light
obliquely
through
anterior
chamber from
lateral side
toward nasal
 side.
Inspection Test for papillary response to Pupils should constrict 1st Visit: The pupil is responding The pupils are reacting
light and reaction to quickly in direct on the light of my penlight. It is in the light of the
accommodation in dimly lit response to light and the constricting when the light is penlight, when it
room. opposite pupil should close and dilated when the light moves away and
1. Instruct client to look also constrict. is moving away. The pupils are moves near on the
straight ahead. Pupil should be equal in equal in size. eyes of the client. The
2. Bring penlight from size. sizes of the pupils are
side of the client’s Papillary 2nd visit: normal.
face to directly in accommodation causes The pupil is responding to the
front of the pupil. constriction in response light of my penlight on the
3. Note quickness or to objects that are near. second visit. When the light is
response to light. Pupillary dilatation close, it constricts, and when the
4. Shine light into same occurs when pupils light moves away, it dilates. The
eye observing for accommodate objects at pupils are all the same size.
response or pupil for a distance, with
equality of size and symmetrical 3rd visit: The pupil is responding
repeat steps to the convergence of eyes. to the light of my penlight during
other eye. the third visit. When the light is
5. Instruct client to gaze close, it is constricting, and
at your finger held 4-6 when the light is moving away,
inches from her nose it is dilated. The pupils are all
then to glance at a the same size.
distant object while
you note papillary
reflex.
6. Move finger toward
the bridge of client’s
nose noting response
of both pupil.
7. Record results
PERRLA (pupils
 equal, round, reactive
to light
accommodation).

8. EARS
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
st
External ear Inspection Examine external ear, called Symmetrical, with upper 1 Visit: The ear is symmetrical, The external is
the auricle or pinna for attachment at eye corner it is in the right level, has no normal. The color
placement, symmetry, color, level, and is fleshed discharges, the color is equal in distributions are
discharge and swelling. colored. the skin and has no presence of normal. There is no
swelling. presence of
discharges.
2nd visit:
On the second visit, the ear is
symmetrical, it is at the proper
level, there are no discharges,
the skin tone is uniform, and
there is no swelling.

Palpation Palpate the auricle between
the thumb and index finger
noting lesions or tenderness
by moving auricle up and
down, same with the mastoid
tip.
3rd visit:
During the third visit, the ear is
symmetrical, it is at the proper
level, there are no discharges,
the skin color is even, and there
is no swelling.
Firm, smooth, free from 1st Visit: The ear of the client The client external ear
lesions and pain. has no lesions, tenderness and has no lesions and the
the texture of the ears smooth. texture of the external
ear smooth.
2nd visit:
On the second appointment, the
 Press inward on tragus noting client's ear is free of lesions,
any tenderness. pain, and has a smooth texture.

3rd visit:
During the third visit, the client's
ear has no lesions, tenderness, or
roughness, and the texture of the
ears is smooth.
Auditory acuity Inspection The Whispered Voice Test The client should be 1st Visit: The client hears the The auditory acuity of
1. Instruct the client to able to repeat whispered word “RAIDER” after it whisper the patient is normal.
occlude one ear with words. it in the both ears.
finger and repeat the
words when heard. 2nd visit:
2. Stand 1-2 feet away The client hears the word
from the client, out of "POCKET" after it is spoken in
view to avoid client both ears on the second visit.
from lip reading, and
softly whisper 3rd visit:
numbers on side of the During the third visit, the client
ears. Increase voice hears the word "PONDS"
volume until client whispered in both ears.
identifies uttered
number.
3. Repeat procedure on
other ear.
4. Record results.

9. NOSE AND SINUSES

AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Nose Inspection Inspect the nose for Located symmetrically, 1st Visit: The nose is The nose is the right
symmetry, deformity, flaring, midline of the face, and symmetrical in the midline of the position and free from
 or inflammation and discharge
from the nares.
Test patency of each nostril:
a. Instruct client to close
the mouth and apply
pressure on one nares
and breathe
b. Repeat test on opposite
nares.
is without swelling, face, free form lesions, swelling any abnormalities or
bleeding, lesions, or and masses. The nostrils of the lesions in the external
masses. client are normal. structure of the nose.
Each nostril is patent. 2nd visit:
The nose is symmetrical in the
middle of the face on the second
visit, with no free-form lesions,
swelling, or tumors. The client
has regular nostrils.

3rd visit:
The nose is symmetrical in the
midline of the face during the
third visit, with free form
lesions, swelling, and masses.
The client's nostrils are normal.
Nasal cavities Inspection Inspect the nasal cavity with a Mucosa is pink or dull 1st Visit: The nasal cavities of The nasal cavities are
penlight: without swelling or the client are pink and has no normal. There is no
a. Tilt client’s head in an polyps. swelling and discharges. The discharges in the nasal
extended position. Septum is midline and septum is intact. cavities.
b. Place non dominant intact.
hand on client’s head A small amount of clear 2nd visit:
using your thumb, and watery discharge is The client's nasal cavities are
lift the tip of the nose. normal. pink on the second visit, with no
c. With the lit penlight, swelling or discharges. The
asses each nostril; and septum is in good condition.
note for color of
anterior nares, nasal 3rd visit:
septum for deviation, During the third visit, the client's
perforation, or nasal cavities are pink, with no
bleeding, and inspect swelling or discharges. The
 for swelling and septum is still intact.
discharge.
Nasal sinuses Palpation Apply gentle upward pressure None-tender air filled 1st Visit: The nasal sinuses of the The nasal sinuses are
on frontal and maxillary areas cavities. client are not tender. The sound not inflamed and
avoiding pressure on the eyes. is normal. swelling. There is sign
Percuss area and note the of discomfort in while
sound. Resonant sound upon 2nd visit: palpating the sinuses.
percussion. The client's nasal sinuses are not
tender during the second visit.
The sound is just normal.

3rd visit:
The client's nasal sinuses are not
tender on the third visit. The
sound is typical.

10. Mouth
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Breath Inspection Stand 12-18 inches in front of Breath should smell 1st Visit: The breath of the client The breath has fresh
client and smell the breath. fresh. has no unnecessary smell. The smell or no
lip is firm, moist and has no unnecessary smell.
Lips Observe lips for color, lesions and inflammation. The lip is normal and
moisture, swelling, lesions free from lesions or
a. Instruct client to open 2nd visit: inflammations. The
mouth and use tongue Lips and mucosa should On the second appointment, the gums are normal in
depressor to retract be pink, firm, and moist client's breath had no unpleasant color, texture and
buccal mucosa and without inflammation or odor. There are no lesions or moisture.
note color, hydration, lesions. inflammation on the lip, and it is
inflammation, or firm and moist.
lesions.
 b. Invert lower lip with
thumbs on inner oral
mucosa and muscle
tone. Repeat procedure
with thumb and index
finger for upper lip.
Gums Inspection Inspect gums for gingivitis
and note color, edema,
retraction, bleeding and
lesions.
Palpation
Palpate gums with tongue
blade for texture
Ask client to clench teeth to
Teeth Inspection assess position and alignment
with the use of a tongue
depressor, expose molars and
note for tartar, cavities,
extraction and color.
3rd visit:
During the third visit, the client's
breath has no unnecessary odor.
The lip is firm and moist, with
no lesions or inflammation.
Gums are pink, smooth 1st Visit: The gums are pink and
and moist. moist.
The texture of the tongue blade
is smooth but has normal color.
Gums are firm.
2nd visit:
The gums are pink and moist on
the second visit.
The tongue blade has a smooth
texture and a normal hue.
3rd visit:
The gums are pink and moist on
the third visit.
Teeth are properly 1st Visit: The teeth are properly The teeth are properly
aligned, smooth, white aligned, smooth, and shiny. Has aligned. Has no
and shiny. no presence of tartar. presence of tartar and
cavities (tooth decay).
2nd visit:
The teeth are perfectly aligned,
smooth, and shining on the
second appointment. There is no
tartar present.

Inspection Instruct client to protrude
tongue:
1. Inspect dorsum of
tongue and note for
color, hydration,
texture, symmetry.
Tongue 2. With penlight, inspect
sides and ventral
surface and note for
Palpation size, texture, nodules,
or ulcerations.
3. Still with penlight,
inspect floor of mouth,
salivary glands, and
duct openings.
Grasp tongue with a gauze
and gently pull it to one side
and palpate full length of
tongue.
Inspection Inspect the soft and hard
palate with a penlight:
Palate a. Instruct client to
extend head backward
3rd visit:
The teeth are properly aligned,
smooth, and shiny after the third
visit. There is no tartar observed.
1st Visit: The tongue of the client The tongue can move
When protruded, tongue is pink color, moist, smooth and freely and has normal
lays midline, medium it can move freely. The dorsal moisture and free form
red or pink in color, surface is free form lesion, lesions.
moist and smooth along inflammation, moist and it has
lateral margins, with the normal texture.
free mobility.
The dorsal surface is 2nd visit:
slightly rough (taste On the second appointment, the
buds) and free from client's tongue is pink in color,
lesions. moist, silky, and moves easily.
The ventral surface is The dorsal surface is free of
highly vascular, smooth, lesions, inflammation, and
moist, and free of moisture, and its texture is
lesions. normal.
3rd visit:
During the third visit, the client's
tongue is pink, moist, smooth,
and free to move. The dorsal
surface is free of lesion,
inflammation, and moisture, and
it has a normal texture.
Palates are concave and 1st Visit: The soft and hard Both palates are
pink. palate is pink and concave. The normal. Has no
Hard palate has ridges. hard palate has ridges and the lesions. The color of
Soft Palate is smooth. soft palate is smooth. the both palates is
 and hold mouth open. normal. Each palate
nd
b. Inspect the hard palate 2 visit: has normal
(roof of mouth) and The soft and hard palates are characteristics.
soft palate for color, pink and concave on the second
shape, lesions. visit. The ridges on the hard
palate are visible, whereas the
soft palate is smooth.

3rd visit:
The soft and hard palates are
pink and concave during the
third visit. The ridges on the
hard palate contrast with the
smoothness of the soft palate.
Inspe4ction Inspect pharynx using tongue With phonation, the soft 1st Visit: The pharynx is pink Each palate has
depressor and penlight: palate and uvula rise and free from any lesions. And normal characteristics.
Pharynx a. Explain procedure to symmetrically. the uvula is perfectly The sizes of the tonsil
client. The pharynx is pink, symmetrical. The tonsil size is are normal and the
b. Instruct client to tilt vascular, lesion free. normal they are not inflamed. pharynx is normal and
head back and open Tonsil size is evaluated When the client says the “ah” the free from lesions. The
mouth. using the grading scale. uvula position is normal and not uvula vibrations are
c. With non-dominant inflamed. normal and it is not
hand, place tongue inflamed and it is
depressor on middle 2nd visit: intact in the right
third of tongue. With The pharynx is pink and devoid position or in the
the dominant hand, of lesions on the second visit. In midline.
shine light into back addition, the uvula is
of throat. symmetrical. The tonsils are
d. Instruct client to say typical in size and are not
“ah” and note irritated. The uvula position is
position, size, normal and not inflamed when
appearance of tonsils the client says "ah."
 and uvula.
e. Inform client of 3rd visit:
eliciting gag reflex by The pharynx is pink and free of
touching the posterior lesions on the third visit. The
1/3 of tongue with uvula is also perfectly
tongue blade if palate symmetrical. The tonsils are
and uvula fail to rise normal in size and are not
symmetrically with inflamed. The uvula position is
phonation. normal and not inflamed when
the client says "ah."

11. NECK
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Inspection Instruct client to: Muscles are 1st Visit: The client can move The neck can move
Symmetry and a. Flex chin to chest and symmetrical with head the neck in full range of motion, freely, free from
Musculature to teach side and in central position. has no presence of discomfort. lesions and the muscle
shoulder to test Movement though full The muscle is equally is symmetrical in the
anterior range of motion without symmetrical in the head and it is head.
sternocleidomastoid complaint of discomfort not inflamed.
muscle. or limitation.
b. Hyperextend the neck 2nd visit:
backward to test On the second visit, the client is
posterior trapezia. able to move his neck in its
entire range of motion and is free
of pain. In the head, the muscle
is equally symmetrical and not
inflamed.

3rd visit:
The client can move the neck in
full range of motion during the

Palpation Palpate lymph nodes and
instruct client to relax and flex be palpable. Small,
neck slightly forward.
1. Stand in front of seated insignificant.
Lymph nodes client.
2. Methodically palpate
both sides of face and
neck simultaneously
with gentle pressure,
move pads and tip of
middle three fingers in
small circular motion.
Follow a systematic
sequence in palpating
the lymph nodes.
3. Note size, shape,
mobility, consistency
and tenderness.
Trachea Inspection Note for position.
Palpation Place thumbs and index finger
on sides of trachea and apply
gentle pressure and palpate.
third visit, and there is no
discomfort. The muscle in the
head is equally symmetrical and
not inflamed.
Lymph nodes should not 1st Visit: The lymph nodes are The lymph nodes are
not palpable, the mobility and not inflamed or
movable nodes are size are normal. swelling.
2nd visit:
The lymph nodes are not
perceptible on the second visit,
and their movement and size are
normal.
3rd visit:
The lymph nodes are not
palpable during the third visit,
and their mobility and size are
normal.
Midline position above 1st Visit: The trachea is normal, The trachea position is
the suprasternal notch. the position is in the midline and the midline and has no
has no presence of discomfort sign of pain when
when palpating it. palpating.
2nd visit:
The trachea is normal on the
second visit, the position is in
the midline, and there is no
discomfort while palpating it.
 3rd visit:
During the third visit, the trachea
is normal, with the position in
the midline and no discomfort
when palpated.

Palpation With client seated, assessment Thyroid cannot be 1st Visit: The client did not show The thyroid of the
may be done with posterior visualized. any discomfort, free from client is normal. There
and anterior approach: tenderness and it is not inflamed is no sign of swelling
Thyroid It may or may not be and bulging. There is no and pain when
A. POSTERIOR felt. presence of unnecessary sounds. palpating.
APPROACH The client can swallow properly.
1. Stand behind client If felt, it should be
and place thumbs on smooth, soft, non-tender 2nd visit:
nape of neck and and not enlarged. On the second appointment, the
bring fingers customer was in no pain, there
interiorly around was no sensitivity, and the area
neck with their tips was not inflamed or bulging.
resting over tracheal There are no superfluous sounds
rings. present. The customer is able to
2. Ask client to tilt swallow normally.
chin forward to
relax neck muscles 3rd visit:
and swallow. During the third visit, the client
3. Palpate the isthmus expressed no discomfort, was
rise under fingers free of tenderness, and the area
and feel each lateral was not inflamed or bulging.
lobe before and There are no unnecessary sounds
while client present. The client is able to
swallow. swallow properly.
4. Ask client to flex
 forward and to left,
and displace thyroid
cartilage to right
with tips of left
fingers. Note any
bulging of gland.
5. Press fingers of left
hand against left
side of thyroid
cartilage to stabilize
Auscultation it while palpating
with the fingers of
right hand while
client swallows.
6. Note consistency,
nodularity, or
tenderness as gland
moves upward.
7. Repeat steps to
opposite side.
B. ANTERIOR APPROACH
1. Stand in front of the
client.
2. Instruct client to tilt
chin forward and
place right thumb on
thyroid cartilage and
displace cartilage to
the right.
3. Grasp elevated
displaced right lobe
with thumb and
 fingers of left hand
and palpate for
consistency,
nodularity or
tenderness as client
swallows.
4. Repeat steps to
opposite side.

If gland appears enlarged,

place the bell of the
stethoscope over gland and
listen for vascular sounds such
as soft, rushing sound, or
bruit.

12. THORAX and LUNGS

AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Inspection Place client in sitting position Respirations are quite, 1st Visit: The breathing pattern is The breathing pattern
with arms folded across chest, effortless, and regular, normal and it has 60 breaths per of the client is normal.
back exposed. with 12-20 breaths per minutes. The thorax is unison on The thorax movements
1. Assess shape and minute. the cycle. The shape and size are unison in the
Shape, symmetry, symmetry by taking Thorax rises and falls in when have a breathing respiratory cycle.
and diameter note of the rate and unison with respiratory movement is normal and There are no sign of
rhythm of respirations, cycle. symmetrical. lesion or unnecessary
movement of chest Ribs slope across and shape. The client can
wall with deep down, without breath easily.
inspiration and full movement or bulging in
expiration. the intercostals spaces. 2nd Visit:
2. Estimate The respiratory rhythm is typical
anteroposterior on the second visit, with 16
 diameter in proportion breaths per minute. On the cycle,
to lateral diameter. the thorax is in synchrony. When
you have a breathing movement,
the shape and size are typical
and symmetrical.

3rd visit:
The breathing pattern is normal
and it has 16 breaths per
minutes. The thorax is unison on
the cycle. The shape and size
when have a breathing
movement is normal and
symmetrical.

Lesions Palpation 1. Palpate for lesions or Thumb should separate 1st Visit: There no presence of
areas of pain. an equal distance of 3- lesion and pain in the area. The
2. Palpate thoracic 5cm and in the same meeting in midline when
expansion at 10th rib by direction during thoracic exhalation and the movements is
placing thumb close to expansion and meet in normal.
client’s spine and the midline on
spread hands over expiration. 2nd visit:
thorax. Note There was no lesion or soreness
divergence of thumbs; Posterior thorax is free in the area on the second visit.
feel for range and from tenderness, lesions Exhalation and movement meet
symmetry of and pulsations. at the midline, which is normal.
movement during deep
inhalation and full Fremitus is equal on 3rd visit:
exhalation. both sides of thorax, During the third visit, there was
3. Place ulnar aspect of strongest at the level o9f no evidence of a lesion or pain in
open hand at right tracheal bifurcation. the area. The meeting in the
 apex of lung and place midline during exhalation and
hand at each posterior movement is normal.
thorax location. Then
instruct client to say
“99” and palpate for
tactile fremitus
(vibrations caused by
vibrations). Note areas
of increased and
decreased fremitus.
4. Move hands from side
to side, from light to
left with client
repeating the words
with the same intensity
every time hands are
placed on the back.
1. Start at lung apices by Air filled lungs create a 1st Visit: The sound when The sound for
moving hands from resonant sound. percussion the lungs is normal. percussing the lungs is
Sound Percussion side to side across the normal.
top of each shoulder. 2nd visit:
Note sound produced The sound when percussioning
from each percussion Identify contralateral the lungs is normal on the
strike and compare sound; bones create flat second visit
with contralateral sound. Thorax is more 3rd visit:
sound. resonant in children and The sound when percussioning
2. Continue downward thin adults. the lungs is normal during the
and post lateral every third visit.
other intercostals
space. Note intensity,
pitch, duration, and
quality of percussion.
 1. Place diaphragm of Posterior sound: 1st Visit: The Breathing sounds The breathing sound
Auscultation stethoscope on right vesicular and of the client is normal. of the clients is normal
lung apex. Instruct bronchovesicular. and has no
client to inhale and 2nd visit: unnecessary sounds.
Breath sounds exhale deeply and Lateral sound: vesicular The client's breathing sounds are
slowly when normal during the second
stethoscope is felt on A large chest will appointment.
the back. Repeat on produce decreased
left lung apex. breath sound. 3rd visit:
2. More downward every The client's breathing sounds are
other intercostals normal during the third visit.
spaces and auscultate,
placing stethoscope in
the same position on
both sides.
3. Auscultate lateral
aspect by placing
stethoscope directly
below right axillae
instructing client to
breath only through
the mouth and to
inhale and exhale
deeply and slowly.
Proceed downward on
every other intercostals
space on the same side.
4. Repeat last step on the
left side.

B. ANTERIOR THORAX
AREA/FEATUR NORMAL KEY ANALYSIS AND
 E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATIO
N
Inspection Place client in sitting position Thorax rises and falls in 1st Visit: The movements of client The symmetry,
or supine position. Inspect unison with respiratory are unison in the respiratory cycle. rhythm and slope are
Symmetry, client’s chest for: cycle, ribs at 45-degree normal.
rhythm and slope 1. Symmetry and depth angle with sternum. 2nd visit:
of movement. Inspiratory breath The client's movements
2. Slope of ribs and sounds are not audible at throughout the respiratory cycle
musculoskeletal a distance of more than are in sync during the second visit.
deformities. 2to 3 cm from mouth.
3rd visit:
During the third visit, the client's
movements are in sync with the
respiratory cycle.
Tenderness, Palpation 1. Place fingerpads on Same normal findings 1st Visit: There are no presence of There are no sign of
pulsation, masses right apex above the with posterior palpation. lesion, masses and respiratory abnormalities and it
and crepitance clavicle. Proceed movement when inhaling and is free form lesions.
downward to each rib exhaling is normal. The expansion The expansions are
and intercostals space of the lungs when inhaling is normal.
and note for normal.
Respiratory tenderness, pulsation,
excursion masses and crepitance. 2nd visit:
Repeat on left side. There are no lesion, masses, or
2. Assess respiratory respiratory movement on the
excursion by placing second visit when inhaling and
thumbs along each exhaling are normal. Inhaling
costal margin with causes the lungs to expand. This is
Tactile Fremitus hands on lateral rib normal.
cage. Instruct client to
inhale deeply; note for 3rd visit:
divergence of thumbs During the third visit, there is no
on expansion; feel evidence of a lesion or masses, and
 range and symmetry of respiratory movement when
respiratory movement. inhaling and exhaling is normal.
3. Palpate for tactile The expansion of the lungs during
fremitus. Gently inhalation is normal.
displace female breasts
as necessary.
Percussion Percuss anterior surface by: Resonant sound over 1st Visit: The resonant sound of The resonant and
1. Percuss 2-3 strikes lung tissue the lungs is normal. The breathing dullness is normal.
along right lung apex (hyperresonance in sound is normal. The breath sound is
and repeat on left lung children and thin adults) normal.
apex. Proceed Cardiac, liver, and 2nd visit:
downward, percussing gastric silhouettes emit The resonant sound of the lungs is
in every ICS going dull sound. normal on the second visit. The
from right to left in Ribs emit flat sound. sound of breathing is normal.
same positions on both
sides. 3rd visit:
The resonant sound of the lungs is
Assess each thorax area: normal during the third visit.
Symmetry and 1. Resonant lung filled. Breathing sounds are normal.
sound 2. Cardiac dullness: 3rd-
5th ICS left of sternum.
3. Liver dullness: place
finger parallel to upper
border of expected
Auscultation liver dullness in right
midclavicular line;
percuss downward.
4. Gastric air bubble:
repeat procedure done
on liver dullness on the
left side.
 Auscultate anterior surface by
instructing client to breath
through the mouth and
compares symmetrical areas
of lungs from above
downward:
1. Listen to breath sounds
and note intensity and
identify variations
from normal.
2. Identify any added Anterior sounds:
sounds by location on bronchial,
chest wall and time in bronchovesicular,
the respiratory cycle. vesicular.
3. If breath sounds are A large chest will
diminished, ask client produce decreased
to breath hard and fast breath sounds.
with mouth open.

13. CARDIOVASCULAR
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Palpation 1. Compress the radial artery Normal Heart rate 1st Visit: The pulse rate is The pulse rate is normal.
with your index finger and normal. It has 60 beats per
Arterial Pulses middle finger. minute.

2nd visit:
The pulse rate is normal on the
second visit. It has a beat rate of
60 beats per minute.

3rd visit:
 The pulse rate is normal on the
third visit. It has a beat rate of
60 beats per minute.

Inspection Precordial Movement 1st Visit: The precordial There is no murmur (S3
1. Position the patient supine movements are normal. The and S4) sound in the
with the head slightly sound of the heart has a single heart. The movements
Heart elevated s1 and s2. are normal.
2. Always examine from the
patient’s right side. 2nd visit:
3. Palpate for point of The precordial motions are
Palpation maximal impulse. normal on the second visit.
(normally located at 4th or There is only one s1 and s2 in
fifth ics, lmcl) the sound of the heart.
4. Listen with diaphragm at
Auscultation the right 2nd ICS 3rd visit:
5. Listen 2nd ICS near sternum. The precordial motions are
6. 3rd, 4th, 5th ICS near sternum normal on the third visit. There
7. Listen for apex is only one s1 and s2 in the
sound of the heart.

Palpation Perform the Allen Test to Palms should turn pink 1st Visit: The color of the palm The tissue prefusion is
determine patency of radial promptly. when compress is white and normal.
and ulnar arteries. Instruct when release it turn to pink
client to rest hands on lap. again.
Tissue perfusion 1. Compress both the
radial and ulnar 2nd Visit:
arteries. On the second visit, the hue of
2. Firmly compress the palm is white when
arteries and instruct compressed and pink when
client to open hand. released.
3. Note color of palms. 3rd visit:
 4. Release one artery The palm is white when
and note the color of compressed and pink when
palm. released on the third visit.
5. Repeat steps on
other artery on the
same hand.

14. ABDOMEN
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATIO
N
Generalized Inspection Placing client in supine Contour is flat or 1st Visit: The contour of the The contour of the
appearance of position with knees flexed over rounded and bilaterally abdomen is flat and symmetrical. client is normal and
abdomen a pillow, hands at side or over symmetrical. symmetrical.
the chest, undrape patient from
xiphoid process to symphysis Umbilicus is depressed 2nd Visit:
pubis to expose abdomen. and beneath the The contour of the abdomen is
1. Inspect abdomen abdominal surface. flat and symmetrical during the
from rib margin to second visit.
pubic bone and note Visible peristalsis is
for contour and slowly transverses the 3rd visit:
symmetry. abdomen in slanting During the third visit, the
2. Inspect umbilicus for downward movements abdomen contour is flat and
contour, location, as observed in thin symmetrical.
signs of inflammation client. Pulsations of the
or hernia. abdominal aorta are
3. Observe for smooth, visible in the epigastric
even respiratory area in thin clients.
movements.
4. Observe for surface
motions (visible
peristalsis)
Bowel sounds Auscultation Auscultate the bowel sounds High pitched sounds 1st Visit: The sound of the bowel The bowel sound is
on the abdominal quadrants heard every 5 to 15 movements is normal in all four normal in all four
using the diaphragm of the seconds as intermittent quadrants. quadrants and has no
stethoscope. gurgling sounds in all 4 presence of
1. Begin by placing the quadrants as a result of 2nd visit: unnecessary sound.
diaphragm on the fluid and air movement The sound of bowel motions is
RLQ. Listen for a full in GIT. normal in all four quadrants on
minute to the the second visit.
frequency and
character of bowel
movements. Bowel sounds should 3rd Visit:
2. Repeat same step always be heard at the The sound of bowel motions is
proceeding in ileocecal valve. normal in all four quadrants on
sequence to RUQ, the third visit.
LUQ, and LLQ.
3. Listen at least for 5
minutes before
concluding the
absence of bowel
sounds.
Abdominal Percussion Begin percussion in RLQ, Tympany is heard 1st Visit: The tympany and The tympanic and
quadrants move upward to RUQ, cross because of air in the dullness of the 4 quadrants is dullness sound of the
over to LUQ, and down to stomach and intestines. normal. four quadrants is
LLQ. Note when tympani Dullness is heard over normal.
changes to dullness. organs. 2nd visit:
The tympany and dullness of the
four quadrants are normal on the
second visit.

3rd visit:
On the third visit, the tympany
and dullness of the four quadrants
 are normal.

15. NEUROLOGIC SYSTEM

ASSESSMENT OF COMMON DEEP TENDON REFLEX

TYPE ASSESSMENT NORMAL REFLEX KEY ANALYSIS AND

FINDINGS INTERPRETATION
1. Flex client’s arm 1st Visit: The flexion of the The biceps can move freely
between 45-degree angle There should be biceps is normal. and has no sign of discomfort.
Biceps and 90 degrees. flexion of arm at
2. Place thumb firmly on elbow. 2nd visit:
biceps tendon just above The flexion of the biceps is
the crease of antecubital normal on the second visit.
fossa.
3. Tap thumb with reflex 3rd visit:
hammer. On the third visit, biceps flexion
is normal.
Triceps 1. Flex client’s arm at 45 Extension of elbow 1st Visit: The extension The elbow can move freely.
degrees and 90-degree movement of the elbow is
angle. normal.
2. Tap triceps tendon just
above the elbow. 2nd visit:
The elbow extension movement
is normal on the second visit.

3rd visit:
The elbow extension movement
is normal on the third visit.
1. Flex client’s arm at 45- Flexion of forearm 1st Visit: The flexion of the The flexion of the forearm is
Brachioradialis degree angle and place forearm is normal. normal.
on lap with the arm
semipronated. 2nd visit:
 2. Tap brachioradialis
tendon on thumb side of
the wrist.
1. Ask the client to sit in a
Patellar chair or on edge of bed
with legs hanging freely
or in supine position with
knee flexed.
2. Tap patellar tendon just
below the patella.
1. Ask client to sit with feet
Achilles dangling and partially
dorsiflexed or in a supine
position with legs flexed
at knee and thigh
externally rotated.
2. Tap the Achilles tendon
just above the heel.
The forearm flexion is normal
on the second visit.
3rd visit:
On the third visit, the forearm
flexion is normal.
Extension of leg 1st Visit: The extension The extension movement of
below the knee. movements of the legs are the legs is normal.
normal and can move freely.
2nd visit:
The extension motions of the
legs are typical on the second
visit, and they can move freely.
3rd visit:
On the third visit, the legs are
typically extended and free to
move.
Plantar flexion of 1st Visit: The one foot can move The one foot cannot move
foot. freely but the one foot is freely or has sign of
showing limitation and cannot discomfort or limitations
react and move easily because because of the supporting
of the supporting brace. braces. But the other foot can
move freely.
2nd visit:
The one foot can move freely on
the second visit, but the other
foot is restricted and cannot
react or move readily due to the
supporting brace.
 3rd visit:
On the third visit, one foot can
move freely, but the other foot
is restricted and cannot react or
move easily due to the
supporting brace.
1. Position client’s ankle 1st Visit: The bending of the The toes can bend downward.
Plantar (Babinski) firmly against the bed. Bending of the toes toes is normal and can fully But they are not reacting
2. Slowly stroke client’s downward. bend normal. The toes are when I stroke it with the
sole with the handle of reacting when a hit it with the reflex hammer.
the reflex hammer. reflex hammer.

2nd visit:
The bending of the toes is
normal on the second visit, and
they can fully bend. When I hit
it with the reflex hammer, the
toes react.

3rd visit:
On the third visit, toe bending is
normal, and they can fully bend.
The toes react when I hit it with
the reflex hammer.

SKILLS IN PHYSICAL ASSESSMENT

SISTER’S NAME: JHAMAICA BACARRO

General Description:
Ms. Jhamaica, who is the eldest son of Mr. & Bacarro, has a brown complexion, black hair and has a mesomorph body type. She also works as Jewelry Appraiser in BHF Paniqui.

VITAL SIGNS
Temperature Respiratory Rate Pulse Rate Blood Pressure Height Weight
st
1 Visit
Date: October 15, 2021 36.7°C 16 breaths per minute 60 beats per minute 90/80 mmHg 157 cm 45 kg

2nd Visit
Date: October 30, 2021 36.7°C 16 breaths per minute 60 beats per minute 90/80 mmHg 157 cm 45 kg

3rd Visit
Date: November 20, 2021 36.5°C 16 breaths per minute 60 beats per minute 90/80 mmHg 157 cm 46 kg

1. SKIN
AREA/FEATUR TECHNIQU NORMAL KEY ANALYSIS AND
E TO ASSESS E SKILLS FINDINGS FINDINGS INTERPRETATION
Color Inspection Inspect variations in skin color Color varies from light 1st Visit: The color of the skin The skin color is
under natural sunlight to ensure to ruddy pink or dark is light brown, the color normal and the
accuracy findings. brown, depending on the distribution is equal, and has no distribution is equal.
race. Color is uniform presence of lesion and masses. There is no presence of
except for sun exposed lesion, masses and
areas or normally nodules.
lighted pigmented areas 2nd Visit:
(nailbeds, palms, lips) in The skin tone is light brown,
dark skinned people. the color distribution is even,
and there are no lesions or
masses on the second visit.

Lesions Inspection Note for color, size, and
anatomic location and
distribution.
Palpation
Palpate lesions with finger pads
for mobility and contour (flat,
raised, or depressed) and
consistency (soft or durable)
3rd visit:
The skin tone is light brown,
the color distribution is even,
and there are no lesions or
masses on the third visit.
Freckles, skin tags in 1st Visit: The skin has no The birthmark is
elderly, and some types presence of wrinkles and normal and the color is
of birthmarks and moles lesions. Has 5 moles in the dark brown
are normal. faces, 12 moles in the body and
a birthmark in the hips. The
texture of skin is slightly dry.
The skin is consistency is
durable and the contour and
mobility is flat.
2nd visit:
On the second appointment,
there are no wrinkles or sores
on the skin. The skin is not dry
texture. The skin's consistency
is long-lasting, and it has a flat
contour and mobility.
3rd visit:
On the third appointment, there
are no wrinkles or sores on the
skin. The skin is not dry texture.
The skin's consistency is long-
lasting, and it has a flat contour
and mobility.
 Moisture Inspection Note amount and distribution Moisture varies with 1st Visit: The skin is slightly The skin is dry.
and activity, body and dry. Because the client of
Palpation environmental the activity of the
temperature, and 2nd visit: client.
humidity in skin folds The skin is smooth and not dry
and the axillae. on the second visit.

3rd visit:
The skin is smooth and not dry
on the third visit.
Temperature Palpation Palpate with dorsum of hand Temperature should be 1st Visit: The temperature is Temperature is normal
noting for uniformity of warmth. uniform and within normal.
normal range.
2nd visit:
The temperature is normal on
the second visit.

3rd visit:
The temperature is normal on
the third visit.

AREA/FEATUR NORMAL KEY ANALYSIS AND

E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Texture (quality, Palpation Palpate with finger pads in Texture is not uniform 1st Visit: The texture of the The texture of the soles
thickness, different areas like the palms and soles palms is slightly rough and and palms are rough
suppleness) are thicker than any slightly rough in the soles. Has and thickness is
areas. Wrinkled and no presence of aging process normal.
leathery skin in the like wrinkles.
elderly results from the
normal aging. Process 2nd visit:
with decreased collagen, On the second visit, the palms
subcutaneous fats, and have a somewhat rough texture,

Mobility and Palpation Assess mobility and turgor to
turgor (elasticity) measure elasticity of skin to
determine the degree of
hydration.
Palpate dependent areas like
the sacrum, feet, and ankles
for mobility by applying
pressure with thumb for 5
seconds. Rate the degree of
edema (accumulation of fluid
in intercellular spaces) by
assessing depth of indention.
Edema may be described on a
scale as follows:
6. 0 = no pitting
7. 1+ = trace/mild
(2mm) pitting
8. 2+ = moderate
(4mm) pitting
sweat glands. and the soles have a slightly
rough texture. There are no
signs of aging, such as
wrinkles.
3rd visit:
On the third visit, the palms
have a somewhat rough texture,
and the soles have a slightly
rough texture. There are no
signs of aging, such as
wrinkles.
Absence of indention is 1st Visit: The skin turgor is The skin turgor is
dependent areas and the normal because the skin returns normal. Because it
resilience of the skin in a second. Has no presence of returns quickly. Has no
spring back to its edema. Because the skin is presence of edema
previous state after turning back in normal or because the skin is
being pinched. previous state after being spring back after poked
pinches and poked by the and pinched. There is
fingers no sign of
dehydrations.
2nd visit:
The skin turgor is normal on the
second visit because the skin
recovers in a split second. There
is no edema present. Because
after being pinched and prodded
by the fingers, the skin returns
to its usual or prior state.
3rd visit:
The skin turgor is normal on the
 9. 3+ = deep/severe third visit because the skin
(6mm) recovers in a split second. There
10. 4+ = very is no edema present. Because
deep/severe after being pinched and prodded
(greater than by the fingers, the skin returns
8mm) to its usual or prior state.
Pinch a fold of skin on the
sternal area using forefinger
and note for the spread with
which it returns to place
(turgor).

2. HAIR
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Color and Inspect Assess for color and Color varies from black 1st Visit: The hair color is black The hair color normally
Distribution distribution of scalp hair, to pale blonde based on with a mixture of brown. The distributes. Has mixture
eyebrows, eyelashes, and the amount of melanin eyelashes, eyebrows and hair in of black and brown.
body surface. present. body surface are color black. The hair in the body
The hair distribution is normal surface, eyebrows and
or equal. eyelashes are color
black. The hair
2nd visit: distribution is normal
On the second visit, the hair is or equal.
black with a brown tinge. Black
eyelashes, eyebrows, and hair
on the body surface. The hair is
distributed evenly or in a
natural pattern.

3rd visit:
The hair is black with a brown
 tinge on the third visit.
Eyelashes, brows, and body hair
are all black. The hair is evenly
distributed or in a natural
pattern.
Texture and Palpation Assess for the skin’s texture Thin, straight, coarse, 1st Visit: The hair is thin, The hair is thin. It is
oiliness and oiliness with the use of thick, or curly. Hair is straight. Shiny and dry. slightly dry. It is easily
palm. shiny and resilient to plucked.
nd
2 visit:
The hair is thin and straight on
the second visit. not gleaming
and dry

3rd visit:
On the third visit, the hair is
thin and straight. not gleaming
and completely dry
infestation Inspection Assess for any presence of Free from any 1st Visit: The hair is free from No infestation in the
infestation by examining the infestation. infestation hair
hair and scalp.
2nd visit:
The hair is free of infestation on
the second visit.

3rd visit:
On the third visit, the hair is
free of infestation.

3. SCALP
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Scaliness and Inspection Part the hair repeatedly all The scalp should be 1st Visit: The scalp is smooth, The scalp is dry and
 scars over the scalp and inspect for
scaliness and scars.
shiny and smooth slightly shiny and dry and no
without lesions, lumps, sign of lesions, mumps and
or masses. masses. But has redness and
scars cause by the flakiness of
the scalp.
flaky (dandruffs) and
no complaint of
discomfort. The only
problem is the
dandruff and dryness.

2nd visit:
The scalp appears smooth,
somewhat shiny, and dry on the
second visit, with no signs of
lesions, mumps, or lumps.
However, the flakiness of the
scalp causes redness and
scarring.

3rd visit:
The scalp appears smooth,
somewhat shiny, and dry on the
third visit, with no signs of
lesions, mumps, or lumps.
However, the flakiness of the
scalp causes redness and
scarring.
Tenderness, Palpation Place finger pads on the scalp Absence of redness or 1st Visit: The scalp has presence The scalp has redness,
lesions, lumps, at the front and palpate down scaliness. redness and tenderness but it is dry and flaky.
masses the midline and each side for slightly flaky. It has moles.
tenderness, lesions, lumps, or
masses. 2nd visit:
The scalp has redness and
tenderness on the second visit,
however it is little flaking. It has
moles on it.
 3rd visit:
The scalp has redness and
tenderness on the third visit,
however it is little flaking. It has
moles on it.

4. NAILS
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
TO ASSESS
Color, shape, and Inspection Inspect for color and shape Nailbeds is highly 1st Visit: The nail beds are pink The nail beds are
texture vascular with a pink color, the shape is round. The normal in color,
color in light skinned texture is smooth and the nails texture and in shape
clients and longitudinal are firm. The nails are not and size.
streaks of brown or clubbing or spooning.
black pigmentation in
dark skinned clients. 2nd visit:
Palpation Palpate nailbed for firmness Angle between The nail beds are pink in color
and texture fingernail and base is and circular in shape on the
about 160 degrees. second visit. The nails are sturdy
and the texture is flawless. The
Nailbed is firm nails aren't spooning or clubbing.

3rd visit:
The nail beds are pink in color
and circular in shape on the third
visit. The nails are sturdy and the
texture is flawless. The nails
aren't spooning or clubbing.
Capillary refill Palpation Press two or more nails When pressure is 1st Visit: The capillary refill is The capillary refill is
between thumb and index released from the nail, it normal because it turning on normal.
 finger and note the degree of
blanching and return to
normal color.
promptly returns to its pink color again.
normal color.
2nd visit:
The capillary refill is typical on
the second visit because the pink
hue has returned.

3rd visit:
The capillary refill is typical on
the third visit because the pink
hue has returned.
Lesions Inspection Inspect the tissue surrounding Tissue surrounding the 1st Visit: The tissues that The tissues that
nails for lesions. nail is intact. surround the nail is free from surround the nail are
lesions and but slightly inflamed. slightly swelled
because the edge of
nd
2 visit: the nail is slightly
The tissues surrounding the nail protrude.
are clear of lesions and mildly
irritated on the second visit.
3rd visit:
The tissues surrounding the nail
are clear of lesions and mildly
irritated on the third visit.

5. SKULL
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Shape and Inspection Inspect skull for shape, Rounded, symmetrical, 1st Visit: The skull is The skull shape and
symmetry symmetry, size in proportion normocephalic, and symmetrical, the shape is round size are symmetrical
to body and position. upright. and the size is proportion. and normal. The
contour of the skull is
2nd visit: normal.
 On the second visit, the skull is
symmetrical, spherical, and
proportional in size.

Contour, Masses, Palpation Palpate with fingerpads
Depressions and beginning in frontal area and
Tenderness continuing over parietal,
temporal, and occipital areas
for contour, masses,
depressions, and tenderness.
3rd visit:
On the third visit, the skull is
symmetrical, spherical, and
proportional in size.
Smooth, non-tender, 1st Visit: The skull is free from The skull has no
free of masses or lesion, mumps or depressions. presence of lesion,
depressions. masses and tenderness.
2nd visit:
The skull is clean of lesions,
mumps, and depressions on the
second visit.

3rd visit:
The skull is clean of lesions,
mumps, and depressions on the
third visit.
6. FACE
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Facial features Inspection Inspect facial features for May be oval, round, or 1st Visit: The face shape is round The face shape is
expression, shape, and square. Symmetrical and has symmetrical features and normal and the facial
symmetry of eyebrows, features and movement. movements. features can move
placement of nose, eyes, and freely with no signs of
ears. 2nd visit: discomfort and pain in
The face form is circular on the the client.
second visit, with symmetrical
features and movements.
 3rd visit:
The face form is circular on the
third visit, with symmetrical
features and movements.
Edema and Inspection Inspect for any presence of No edema and masses 1st Visit: There are no presence The acnes are little
masses edema and masses of edema and masses. But has a and there are not red
fewer acne and it is slightly oily. in color. There is no
It has 9 moles. The color presence of edema and
distribution of the skin of the masses.
face normal is equal.

2nd visit:
Edema and masses were not
present on the second visit. It has
a total of 9 moles. The usual
color distribution of the skin of
the face is uniform.

3rd visit:
Edema and masses were not
present on the second visit. It has
a total of 9 moles. The usual
color distribution of the skin of
the face is uniform.

7. EYES
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Visual Acuity Inspection Test visual acuity. Normal vision based on 1st Visit: The vision is 20/20 or The visual acuity is
8. Position Snellen chart the Snellen chart is 20/20 normal. The client has no normal.
20 ft. in front of client. at the distance of 20 feet corrective lens.
9. Remove corrective the normal eye can read
 lenses, if appropriate. the chart). 2nd visit:
10. Instruct client to cover The vision was remained 20/20
one eye and read lines or normal on the second
starting with top of appointment. The client does not
chart from left to right. have any corrective lenses.
11. Note the line where
client reads more than 3rd visit:
half of the letters. The vision was remained 20/20
12. Record results as a or normal on the third
fraction sc (without appointment. The client does not
correction), 20/ have any corrective lenses.
distance number, and
the number of the
letters missed.
13. Repeat same steps for
the other eye.
14. If appropriate, repeat
steps with patient
wearing the corrective
device.
Inspection Test eye for extraocular Eye movement should 1st Visit: The eye movement is The eye movements
muscle movements: be symmetrical as both normal and symmetrical when are normal. It can
9. Place the client in eyes follow the direction following the objects. follow the object
sitting position. of the gaze and easily.
10. Instruct the client to converge on the held 2nd visit:
hold head still. object as its moves The vision was remained 20/20
11. Ask the client to toward the nose. or normal on the second
follow an object with appointment. The client does not
eyes. have any corrective lenses.
12. Move objects with 6
fields of gaze. 3rd visit:
The vision was remained 20/20
 or normal on the third
appointment. The client does not
have any corrective lenses.
***The 6 Fields of Gaze 1st Visit: The gaze of the patient The client can follow
7. Conjugate left lateral when following the objects is the object easily in the
gaze normal has no nystagmus. six field of gaze. Has
8. Left down and lateral no sign or presence of
gaze 2nd visit: involuntary
9. Right down and lateral The patient's gaze is normal movement.
gaze when following the objects on
10. Conjugate right lateral the second visit, with no
gaze nystagmus.
11. Right up and lateral
gaze 3rd visit:
12. Left up and lateral The patient's gaze is normal
13. Observe for parallel The upper eyelids cover when following the objects on
eye movement. only the uppermost part the third visit, with no
14. Pause during upward of the iris and are free nystagmus.
and lateral gaze field from nystagmus
to detect in voluntary (involuntary rhythmical
rhythmic oscillation of oscillation of the eyes).
eyes. A few beats of
15. Note position of upper nystagmus with extreme
eyelid in relation to lateral gaze can be
the iris and eyelid bag normal.
as the client’s eye
move from up and
down.
16. Move object forward
to about 5 inches in
front of the client’s
nose at the midline
 and observe for
convergence, and
record result.
External Inspection Observe upper eyelid.
anatomical
structures Check eyes and eyelids for
inflammation, crusting,
edema or masses.
Inspect lacrimal glands and
sacs for swelling.
Palpation Check for blocking of
nasolacrimal duct by pressing
against inner orbital rim of
lacrimal sac.
Inspect duct by palpating on
the lacrimal sac and observing
for regurgitation of fluid.
Inspection Inspect bulbar and palpebral
conjuctiva and sclera.
Upper eyelid should 1st Visit: The upper eyelid is The external structures
overlap iris. normal and has no presence of of the eyes are normal.
edema, inflammation and The upper eyelids
Eyes and eyelids should masses. have no presence of
be free from crusting and
inflammation, crusting, 2nd visit: inflammation. The has
edema or masses. The upper eyelid is normal on no presence of edema.
the second visit, with no edema,
irritation, or tumors.
3rd visit:
The upper eyelid is normal on
the third visit, with no edema,
irritation, or tumors.
Lacrimal gland should 1st Visit: The lacrimal gland is The lacrimal gland is
not be palpable. not palpable and tears is flowing not palpable or there
freely. are in normal size. The
Tears flow freely from tears are flowing
the lacrimal gland over 2nd visit: freely.
the cornea and The lacrimal gland is no longer
conjunctiva to the perceptible on the second visit,
lacrimal duct. and tears are freely flowing.
3rd visit:
The lacrimal gland is no longer
perceptible on the third visit, and
tears are freely flowing.
Bulbar is transparent 1st Visit: The bulbar, palpebral The bulbar, palpebral,
with small blood conjunctiva and sclera is normal. sclera and the pupil of
d. Instruct client to look vessels. The sclera is color white with both eyes are normal
upward while Palpebral conjunctiva some blood vessels. The
depressing lower lid covering the inside of palpebral is moist and has
with thumb. the upper and lower normal color. The corneas are
e. Inspect for color, eyelids is pink and shiny, moist and clear. The
redness, swelling, moist. diameter of the pupil is normal
exudates, or foreign Sclera is white with and has black color. When I
bodies. some superficial blood move my penlight, the pupil is
f. Inspect cornea, lenses, vessels depending on responding normal. The
pupil, iris, and anterior the race. conjunctiva is color pink and not
chamber: dry
1. Stand in front Corneas are moist, shiny
of the client. and clear. 2nd visit:
2. Shine penlight Lenses are transparent. The bulbar, palpebral
directly on Pupils are black, round conjunctiva, and sclera are
cornea. and equal diameter, normal on the second visit. The
3. Move light ranging from 2-6mm. sclera is white in hue and
laterally and Entire iris should contains some blood veins. The
view cornea illuminate when shining palpebral is moist, and the color
from that light laterally too is normal. The corneas are clear,
angle; note nasally. lustrous, and moist. The pupil
color, has a normal diameter and a
discharge, and black color. The pupil responds
lesions. normally when I shift my
4. Look at pupil penlight. The conjunctiva is pink
and note size in hue and is not dry.
and shape.
5. Shine penlight 3rd visit:
directly on The bulbar, palpebral
pupils to assess conjunctiva, and sclera are
lens and color. normal on the third visit. The
6. Look at iris for sclera is white in hue and
 size, and contains some blood veins. The
ability of palpebral is moist, and the color
pupils to react is normal. The corneas are clear,
to light. lustrous, and moist. The pupil
7. Shine a light has a normal diameter and a
obliquely black color. The pupil responds
through normally when I shift my
anterior penlight. The conjunctiva is pink
chamber from in hue and is not dry.
lateral side
toward nasal
side.
Inspection Test for papillary response to Pupils should constrict 1st Visit: The pupil reacting Both pupils are
light and reaction to quickly in direct (contracting) quickly when the reacting normally in
accommodation in dimly lit response to light and the light is moving near and dilated the light of the
room. opposite pupil should when slowly moving far away. penlight. The pupils
8. Instruct client to look also constrict. are constricting when
straight ahead. Pupil should be equal in 2nd visit: the penlight is near in
9. Bring penlight from size. On the second visit, the pupil no the eyes and dilated
side of the client’s Papillary reacts . when moving far away
face to directly in accommodation causes in the eye
front of the pupil. constriction in response 3rd visit:
10. Note quickness or to objects that are near. On the third visit, the pupil no
response to light. Pupillary dilatation reacts .
11. Shine light into same occurs when pupils
eye observing for accommodate objects at
response or pupil for a distance, with
equality of size and symmetrical
repeat steps to the convergence of eyes.
other eye.
12. Instruct client to gaze
at your finger held 4-6
 inches from her nose
then to glance at a
distant object while
you note papillary
reflex.
13. Move finger toward
the bridge of client’s
nose noting response
of both pupil.
14. Record results
PERRLA (pupils
equal, round, reactive
to light
accommodation).

8. EARS
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
st
External ear Inspection Examine external ear, called Symmetrical, with upper 1 Visit: The ears are The are in the right
the auricle or pinna for attachment at eye corner symmetrical, there are in the position and level. The
placement, symmetry, color, level, and is fleshed right level and the color is color is normal.
discharge and swelling. colored. normal.

2nd visit:
The ears are symmetrical, in the
right level, and the color is
normal on the second visit.

3rd visit:
The ears are symmetrical, in the
right level, and the color is
normal on the third visit.
 Palpation Palpate the auricle between
the thumb and index finger
noting lesions or tenderness
by moving auricle up and
down, same with the mastoid
tip.
Press inward on tragus noting
any tenderness.
Firm, smooth, free from 1st Visit: The external ears are The external ear is
lesions and pain. smooth, firm and free from normal.
lesions and pain.
2nd visit:
The external ears are smooth,
solid, and free of lesions and
pain at the second visit.

3rd visit:
The external ears are smooth,
solid, and free of lesions and
pain at the third visit.
Auditory acuity Inspection The Whispered Voice Test The client should be 1st Visit: The client heard the The auditory acuity is
5. Instruct the client to able to repeat whispered word “AXIE” clearly in both normal.
occlude one ear with words. ears after it whispered it in 1-2
finger and repeat the feet away
words when heard.
6. Stand 1-2 feet away 2nd visit:
from the client, out of The client heard the term
view to avoid client "KEYBOARD" clearly in both
from lip reading, and ears on the second visit when it
softly whisper was murmured in 1-2 feet
numbers on side of the distant.
ears. Increase voice
volume until client 3rd visit:
identifies uttered The client heard the term
number. "PAPER" clearly in both ears on
7. Repeat procedure on the second visit when it was
other ear. murmured in 1-2 feet distant.
8. Record results.
9. NOSE AND SINUSES
AREA/FEATUR
E TO ASSESS TECHNIQUE SKILLS
Nose Inspection Inspect the nose for
symmetry, deformity, flaring,
or inflammation and discharge
from the nares.
Test patency of each nostril:
c. Instruct client to close
the mouth and apply
pressure on one nares
and breathe
d. Repeat test on opposite
nares.
Nasal cavities Inspection Inspect the nasal cavity with a
penlight:
d. Tilt client’s head in an
extended position.
e. Place non dominant
hand on client’s head
using your thumb, and
lift the tip of the nose.
f. With the lit penlight,
NORMAL KEY ANALYSIS AND
FINDINGS FINDINGS INTERPRETATION
Located symmetrically, 1st Visit: The location of the The location of the
midline of the face, and nose is in the midline and nose is normal. Has no
is without swelling, symmetrical and has no presence presence of lesions.
bleeding, lesions, or of swelling, lesion and
masses. discharges. The nostrils are
patent.
Each nostril is patent.
2nd visit:
On the second visit, the nose is
symmetrical and located in the
midline, with no swelling,
lesions, or discharges. Nostrils
are visible.
3rd visit:
On the third visit, the nose is
symmetrical and located in the
midline, with no swelling,
lesions, or discharges. Nostrils
are visible.
Mucosa is pink or dull 1st Visit: The nasal cavity is pink The nasal cavity is
without swelling or in color and has no presence of normal and has no
polyps. swelling. The septum is intact in presence of
Septum is midline and the midline. Has no presence of discharges.
intact. discharges.
A small amount of clear
watery discharge is 2nd visit:
normal. The nasal cavity is pink and
there is no edema on the second
 asses each nostril; and visit. In the middle, the septum is
note for color of unbroken. No discharges can be
anterior nares, nasal found.
septum for deviation,
perforation, or 3rd visit:
bleeding, and inspect The nasal cavity is pink and
for swelling and there is no edema on the third
discharge. visit. In the middle, the septum is
unbroken. No discharges can be
found.
Nasal sinuses Palpation Apply gentle upward pressure None-tender air filled 1st Visit: The nasal sinuses of the The nasal sinuses are
on frontal and maxillary areas cavities. client are not tender. The sound normal. The resonant
avoiding pressure on the eyes. is normal sound is normal.
Percuss area and note the
sound. Resonant sound upon 2nd visit:
percussion. The client's nasal sinuses are not
tender at the second
appointment. The sound is
typical.

3rd visit:
The client's nasal sinuses are not
tender at the third appointment.
The sound is typical.

10. Mouth
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
st
Breath Inspection Stand 12-18 inches in front of Breath should smell 1 Visit: The client has no The client has a
client and smell the breath. fresh. unnecessary smell in the breath. pleasant and fresh
The lip is pink, firm and slightly breath. The lip is pink
Lips Observe lips for color, dry and free from inflammations in color and slight dry.
moisture, swelling, lesions and lesions.
c. Instruct client to open
mouth and use tongue Lips and mucosa should 2nd visit:
depressor to retract be pink, firm, and moist On the second appointment, the
buccal mucosa and without inflammation or client's breath is free of any
note color, hydration, lesions. unwanted odors. Lips are pink,
inflammation, or firm, and somewhat dry, with no
lesions. inflammations or blemishes.
d. Invert lower lip with
thumbs on inner oral 3rd visit:
mucosa and muscle On the third appointment, the
tone. Repeat procedure client's breath is free of any
with thumb and index unwanted odors. Lips are pink,
finger for upper lip. firm, and somewhat dry, with no
inflammations or blemishes.

Gums Inspection Inspect gums for gingivitis
and note color, edema,
retraction, bleeding and
lesions.
Palpation
Palpate gums with tongue
blade for texture
Gums are pink, smooth 1st Visit: The gums are pink, The gums are normal
and moist. firm, smooth and moist. It free in color and they are
from lesions and edema. moisture.
2nd visit:
Gums are firm. Gums are pink, hard, smooth,
and moist during the second
visit. It is devoid of lesions and
edema.

3rd visit:
Gums are pink, hard, smooth,
and moist during the third visit.
It is devoid of lesions and
edema.
 Ask client to clench teeth to
Teeth Inspection assess position and alignment
with the use of a tongue
depressor, expose molars and
note for tartar, cavities,
extraction and color.
Inspection Instruct client to protrude
tongue:
4. Inspect dorsum of
tongue and note for
color, hydration,
texture, symmetry.
Tongue 5. With penlight, inspect
sides and ventral
surface and note for
Palpation size, texture, nodules,
or ulcerations.
6. Still with penlight,
inspect floor of mouth,
Teeth are properly 1st Visit: The client has a The client has
aligned, smooth, white corrective alignment in the teeth corrective alignment
and shiny. both upper and lower (retainer), in the teeth to reduce
has no cavities, tartar and the or adjust the spaces of
color of the teeth is white. the teeth. Has no
presence of cavity
2nd visit: (tooth decay) and
The customer has a corrective tartar. The color of the
alignment in both upper and teeth is white.
lower teeth (braces), no cavities,
tartar, and the teeth are white on
the second visit.
3rd visit:
The customer has a corrective
alignment in both upper and
lower teeth (braces), no cavities,
tartar, and the teeth are white on
the third visit.
1st Visit: The tongue of the client The tongue can move
When protruded, tongue is pink color, moist, smooth and freely. The dorsal
lays midline, medium it can move freely. The dorsal surfaces is normal.
red or pink in color, surface is free form lesion,
moist and smooth along inflammation, moist and it has
lateral margins, with the normal texture.
free mobility.
The dorsal surface is 2nd visit:
slightly rough (taste The client's tongue is pink in
buds) and free from color, moist, silky, and moves
lesions. easily on the second
The ventral surface is appointment. The dorsal surface
highly vascular, smooth, is devoid of lesions,
 salivary glands, and
duct openings.
Grasp tongue with a gauze
and gently pull it to one side
and palpate full length of
tongue.
Inspection Inspect the soft and hard
palate with a penlight:
Palate c. Instruct client to
extend head backward
and hold mouth open.
d. Inspect the hard palate
(roof of mouth) and
soft palate for color,
shape, lesions.
Inspe4ction Inspect pharynx using tongue
depressor and penlight:
Pharynx f. Explain procedure to
moist, and free of inflammation, and moisture, and
lesions. the texture is normal.
3rd visit:
The client's tongue is pink in
color, moist, silky, and moves
easily on the third appointment.
The dorsal surface is devoid of
lesions, inflammation, and
moisture, and the texture is
normal.
Palates are concave and 1st Visit: The soft and hard Both palates are
pink. palate is pink and concave. The normal. Has no
Hard palate has ridges. hard palate has ridges and the lesions. The color of
Soft Palate is smooth. soft palate is smooth the both palates is
normal. Each palate
2nd visit: has normal
The soft and hard palates are characteristics.
pink and concave on the second
visit. The ridges on the hard
palate are visible, whereas the
soft palate is smooth.
3rd visit:
The soft and hard palates are
pink and concave on the third
visit. The ridges on the hard
palate are visible, whereas the
soft palate is smooth.
With phonation, the soft 1st Visit: The pharynx is pink Each palate has
palate and uvula rise and free from any lesions. And normal characteristics.
symmetrically. the uvula is perfectly The sizes of the tonsil
 client. The pharynx is pink, symmetrical. The tonsil size is are normal and the
g. Instruct client to tilt vascular, lesion free. normal they are not inflamed. pharynx is normal and
head back and open Tonsil size is evaluated When the client says the “ah” the free from lesions. The
mouth. using the grading scale. uvula position is normal and not uvula vibrations are
h. With non-dominant inflamed normal and it is not
hand, place tongue inflamed and it is
depressor on middle 2nd visit: intact in the right
third of tongue. With The pharynx is pink and clear of position or in the
the dominant hand, lesions at the second midline.
shine light into back appointment. Furthermore, the
of throat. uvula is symmetrical. Tonsils are
i. Instruct client to say not inflamed and have a normal
“ah” and note size. The uvula position is
position, size, normal and uninflamed when the
appearance of tonsils client speaks "ah."
and uvula.
j. Inform client of 3rd visit:
eliciting gag reflex by At the third appointment, the
touching the posterior pharynx is pink and free of
1/3 of tongue with lesions. In addition, the uvula is
tongue blade if palate symmetrical. Tonsils are normal
and uvula fail to rise in size and do not appear to be
symmetrically with inflamed. When the client says
phonation. "ah," the uvula position is
normal and uninflamed.

11. NECK
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Inspection Instruct client to: Muscles are 1st Visit: The client can move The client neck can
Symmetry and c. Flex chin to chest and symmetrical with head the neck freely and has no move freely and has
Musculature to teach side and in central position. presence of discomfort at no sign of discomfort
 shoulder to test Movement though full limitations. The muscle is and pain. The muscle
anterior range of motion without symmetrical in the head. in the neck is
sternocleidomastiod complaint of discomfort symmetrical in the
muscle. or limitation. 2nd visit: head of the client.
d. Hyperextend the neck The client can move his neck
backward to test fully on the second appointment,
posterior trapezia. and there is no discomfort at the
restrictions. In the head, the
muscle has symmetry.

3rd visit:
On the third appointment, the
client can fully move his neck
and there is no discomfort from
the restrictions. The muscle is
symmetrical in the head.
Palpation Palpate lymph nodes and Lymph nodes should not 1st Visit: The lymph nodes are The lymph nodes are
instruct client to relax and flex be palpable. Small, not palpable (not inflamed), the not palpable. They are
neck slightly forward. movable nodes are mobility and size are normal. not swelling.
4. Stand in front of seated insignificant.
Lymph nodes client. 2nd visit:
5. Methodically palpate The lymph nodes are not
both sides of face and perceptible (uninflamed) on the
neck simultaneously second visit, and their mobility
with gentle pressure, and size are normal.
move pads and tip of
middle three fingers in 3rd visit:
small circular motion. On the third visit, the lymph
Follow a systematic nodes are not visible
sequence in palpating (uninflamed), and their mobility
the lymph nodes. and size are normal.
6. Note size, shape,
 mobility, consistency
and tenderness.
Trachea Inspection Note for position.
Palpation Place thumbs and index finger
on sides of trachea and apply
gentle pressure and palpate.
Palpation With client seated ,
assessment may be done with
posterior and anterior
Thyroid approach:
C. POSTERIOR
APPROACH If felt, it should be
1. Stand behind client smooth, soft, non tender
and place thumbs on and not enlarged.
nape of neck and
bring fingers
interiorly around
neck with their tips
resting over tracheal
Midline position above 1st Visit: The trachea is normal, The trachea position is
the suprasternal notch. the position is in the midline and the midline and has no
has no presence of discomfort sign of pain when
when palpating it. palpating.
2nd visit:
The trachea is normal, the
position is in the midline, and
there is no discomfort while
palpating it on the second visit.
3rd visit:
The trachea is normal, the
position is in the midline, and
there is no discomfort while
palpating it on the third visit.
Thyroid cannot be 1st Visit: The client did not show The thyroid of the
visualized. any discomfort, free from client is normal. There
tenderness and it is not inflamed is no sign of swelling
It may or may not be and bulging. There is no and pain when
felt. presence of unnecessary sounds. palpating
The client can swallow properly.
2nd visit:
On the second appointment, the
customer was in no pain, there
was no sensitivity, and the area
was not inflamed or bulging.
There are no superfluous sounds
present. The customer is able to
 rings. swallow normally.
2. Ask client to tilt
chin forward to 3rd visit:
relax neck muscles The customer was in no pain,
and swallow. had no sensitivity, and the area
3. Palpate the isthmus was not inflamed or bulging at
rise under fingers the third appointment. There are
and feel each lateral no unnecessary sounds present.
lobe before and The customer can swallow
while client normally.
swallow.
4. Ask client to flex
forward and to left,
and displace thyroid
cartilage to right
with tips of left
fingers. Note any
bulging of gland.
5. Press fingers of left
hand against left
side of thyroid
Auscultation cartilage to stabilize
it while palpating
with the fingers of
right hand while
client swallows.
6. Note consistency,
nodularity, or
tenderness as gland
moves upward.
7. Repeat steps to
opposite side.
 D. ANTERIOR APPROACH
1. Stand in front of the
client.
2. Instruct client to tilt
chin forward and
place right thumb on
thyroid cartilage and
displace cartilage to
the right.
3. Grasp elevated
displaced right lobe
with thumb and
fingers of left hand
and palpate for
consistency,
nodularity or
tenderness as client
swallows.
4. Repeat steps to
opposite side.

If gland appears enlarged,

place the bell of the
stethoscope over gland and
listen for vascular sounds such
as soft, rushing sound, or
bruit.

12. THORAX and LUNGS

AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Inspection Place client in sitting position Respirations are quite, 1st Visit: The respirations are The client has normal
 with arms folded across chest, effortless, and regular, effortless and regular. The client breath per minute. The
back exposed. with 12-20 breaths per has 16 breaths per minutes. The client has effortless in
3. Assess shape and minute. respiratory cycle is normal respirations. The
Shape, symmetry, symmetry by taking Thorax rises and falls in because the thorax is unison on thorax is unison in the
and diameter note of the rate and unison with respiratory the cycle of breathing. cycle of breathing.
rhythm of respirations, cycle.
movement of chest Ribs slope across and 2nd visit:
wall with deep down, without The respirations are effortless
inspiration and full movement or bulging in and regular on the second visit.
expiration. the intercostals spaces. The customer breathes at a rate
4. Estimate of 16 breaths per minute.
anteroposterior Because the thorax moves in
diameter in proportion lockstep with the respiratory
to lateral diameter. cycle, the respiratory cycle is
normal.

3rd visit:
The respirations are effortless
and regular on the second visit.
The customer breathes at a rate
of 16 breaths per minute.
Because the thorax moves in
lockstep with the respiratory
cycle, the respiratory cycle is
normal.
Lesions Palpation 5. Palpate for lesions or Thumb should separate 1st Visit: There no presence of There is no sign of
areas of pain. an equal distance of 3- lesions and pain in the area. The lesions and the
6. Palpate thoracic 5cm and in the same meeting in midline when vibration is normal
th
expansion at 10 rib by direction during thoracic exhalation and the movements is when the client says
placing thumb close to expansion and meet in normal. The vibrations are the “99”. The
client’s spine and the midline on normal when the client said the breathing movements
spread hands over expiration. “99”. is normal.
 thorax. Note
divergence of thumbs; Posterior thorax is free 2nd visit:
feel for range and from tenderness, lesions There were no lesions or
symmetry of and pulsations. soreness in the area after the
movement during deep second visit. When you exhale
inhalation and full Fremitus is equal on and move, you should meet in
exhalation. both sides of thorax, the middle. When the client said
7. Place ulnar aspect of strongest at the level o9f "Seven," the tremors were
open hand at right tracheal bifurcation. normal.
apex of lung and place
hand at each posterior 3rd visit:
thorax location. Then There were no lesions or
instruct client to say soreness in the area after the
“99” and palpate for second visit. When you exhale
tactile fremitus and move, you should meet in
(vibrations caused by the middle. When the client said
vibrations). Note areas "BOTTLE," the tremors were
of increased and normal.
decreased fremitus.
8. Move hands from side
to side, from light to
left with client
repeating the words
with the same intensity
every time hands are
placed on the back.
3. Start at lung apices by Air filled lungs create a 1st Visit: The sound when The sound of the lungs
moving hands from resonant sound. percussion the lungs is normal when it taps or
Sound Percussion side to side across the percussion is normal.
top of each shoulder. 2nd visit:
Note sound produced The sound when percussioning
from each percussion Identify contralateral the lungs is normal on the
 strike and compare sound; bones create flat second visit.
with contralateral sound. Thorax is more
sound. resonant in children and 3rd visit:
4. Continue downward thin adults. The sound when percussioning
and post lateral every the lungs is normal on the third
other intercostals visit.
space. Note intensity,
pitch, duration, and
quality of percussion.
5. Place diaphragm of Posterior sound: 1st visit: The Breathing sounds The breathing sounds
Auscultation stethoscope on right vesicular and of the client is normal. Has no is normal.
lung apex. Instruct bronchovesicular. presence of unnecessary sound.
client to inhale and
Breath sounds exhale deeply and Lateral sound: vesicular 2nd visit:
slowly when The client's breathing sounds
stethoscope is felt on A large chest will were normal during the second
the back. Repeat on produce decreased appointment. There is no
left lung apex. breath sound. extraneous sound present.
6. More downward every
other intercostals 3rd visit:
spaces and auscultate, The client's breathing sounds
placing stethoscope in were normal during the third
the same position on appointment. There is no
both sides. extraneous sound present.
7. Auscultate lateral
aspect by placing
stethoscope directly
below right axillae
instructing client to
breath only through
the mouth and to
inhale and exhale
 deeply and slowly.
Proceed downward on
every other intercostals
space on the same side.
8. Repeat last step on the
left side.
B. ANTERIOR THORAX
AREA/FEATUR
E TO ASSESS TECHNIQUE SKILLS
Inspection Place client in sitting position
or supine position. Inspect
Symmetry, client’s chest for:
rhythm and slope 3. Symmetry and depth
of movement.
4. Slope of ribs and
musculoskeletal
deformities.
Tenderness, Palpation 4. Place fingerpads on
pulsation, masses right apex above the
and crepitance clavicle. Proceed
downward to each rib
and intercostals space
and note for
Respiratory tenderness, pulsation,
NORMAL KEY ANALYSIS AND
FINDINGS FINDINGS INTERPRETATIO
N
Thorax rises and falls in 1st Visit: The movements of The symmetry.
unison with respiratory client are unison in the respiratory Rhythm and slopes
cycle, ribs at 45-degree cycle. are normal.
angle with sternum.
Inspiratory breath 2nd visit:
sounds are not audible at The client's movements
a distance of more than throughout the respiratory cycle
2to 3 cm from mouth. are in sync during the second
visit.
3rd visit:
The client's movements
throughout the respiratory cycle
are in sync during the third visit.
Same normal findings 1st Visit: There are no presence of There are no lesions
with posterior palpation. lesion, tenderness, masses and or any abnormalities.
respiratory movement normal. The respiratory
The inhaling and exhaling movements are
movement is normal. The normal.
expansion of the lungs when
inhaling is normal.
 excursion masses and crepitance.
Repeat on left side. 2nd visit:
5. Assess respiratory There are no lesions, discomfort,
excursion by placing or lumps on the second visit, and
thumbs along each respiratory movement is normal.
costal margin with It is normal to inhale and exhale.
Tactile Fremitus hands on lateral rib Inhaling causes a natural
cage. Instruct client to expansion of the lungs.
inhale deeply; note for 3rd visit:
divergence of thumbs There are no lesions, discomfort,
on expansion; feel or lumps on the third visit, and
range and symmetry of respiratory movement is normal.
respiratory movement. It is normal to inhale and exhale.
6. Palpate for tactile Inhaling causes a natural
fremitus. Gently expansion of the lungs.
displace female breasts
as necessary.
Percussion Percuss anterior surface by: Resonant sound over 1st Visit: The resonant sound of The resonant and
2. Percuss 2-3 strikes lung tissue the lungs is normal. The dullness is normal.
along right lung apex (hyperresonance in breathing sound is normal.
and repeat on left lung children and thin adults)
apex. Proceed Cardiac, liver, and 2nd visit:
downward, percussing gastric silhouettes emit The lungs' resonant sound has
in every ICS going dull sound. returned to normal on the second
from right to left in Ribs emit flat sound. visit. The sound of normal
same positions on both breathing is audible.
sides.
3rd visit:
Assess each thorax area: The lungs' resonant sound has
Symmetry and 5. Resonant lung filled. returned to normal on the third
sound 6. Cardiac dullness: 3rd- visit. The sound of normal
5th ICS left of sternum. breathing is audible.
 7. Liver dullness: place
finger parallel to upper
border of expected
Auscultation liver dullness in right
midclavicular line;
percuss downward.
8. Gastric air bubble:
repeat procedure done
on liver dullness on the
left side.

Auscultate anterior surface by

instructing client to breath
through the mouth and
compares symmetrical areas
of lungs from above
downward:
4. Listen to breath sounds
and note intensity and
identify variations
from normal.
5. Identify any added Anterior sounds:
sounds by location on bronchial,
chest wall and time in bronchovesicular,
the respiratory cycle. vesicular.
6. If breath sounds are A large chest will
diminished, ask client produce decreased
to breath hard and fast breath sounds.
with mouth open.

13. CARDIOVASCULAR
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
st
Palpation 2. Compress the radial artery Normal Heart rate 1 Visit: The heart rate of the The pulse rate is normal.
with your index finger and client is normal because it has
Arterial Pulses middle finger. 96 beats pre minutes.

2nd visit:
The lungs' resonant sound has
returned to normal on the
second visit. The sound of
normal breathing is audible.
3rd visit:
The lungs' resonant sound has
returned to normal on the third
visit. The sound of normal
breathing is audible.
Inspection Precordial Movement 1st Visit: The precordial There are no s3 and s4
8. Position the patient supine movements are normal. The sound or unnecessary
with the head slightly sound of the heart has a single sound (murmur) after
Heart elevated s1 and s2. It has no presence of auscultation the sounds.
9. Always examine from the S3 or S4 or unnecessary sound. The movements are
patient’s right side. normal.
10. Palpate for point of 2nd visit:
Palpation maximal impulse. The precordial motions are
(normally located at 4th or normal at the second visit. The
fifth ics, lmcl) heart has a single s1 and s2
11. Listen with diaphragm sound. There is no S3 or S4
Auscultation at the right 2nd ICS present, and there is no
12. Listen 2nd ICS near extraneous sound.
sternum.
13. 3rd, 4th, 5th ICS near 3rd visit:
sternum At the third visit, the precordial
14. Listen for apex motions are normal. A single s1
 and s2 sound is produced by the
heart. There is no S3 or S4, nor
is there any extraneous sound.
Palpation Perform the Allen Test to 1st Visit: The color of the palm The tissue prefusion is
determine patency of radial when compress is white and normal.
and ulnar arteries. Instruct when release it turn to pink
client to rest hands on lap. again.
Tissue perfusion 6. Compress both the Palms should turn pink
radial and ulnar promptly. 2nd visit:
arteries. When the palm is compressed
7. Firmly compress on the second visit, it turns
arteries and instruct white, then pink again when it is
client to open hand. released.
8. Note color of palms.
9. Release one artery 3rd visit:
and note the color of On the third visit, when the
palm. palm is compressed, it turns
10. Repeat steps on white, then pink again when
other artery on the released.
same hand.

14. ABDOMEN
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATIO
N
Generalized Inspection Placing client in supine 1st Visit: The patient contour of The shape is slight
appearance of position with knees flexed over abdomen is slightly round but it is round and it connect
abdomen a pillow, hands at side or over normal because the patient has in the body physique
the chest, undrape patient from oval body physique and chubby of the client. The
xiphoid process to symphysis body. contour is normal.
pubis to expose abdomen.
5. Inspect abdomen 2nd visit:
 from rib margin to The patient contour of abdomen
pubic bone and note Contour is flat or is slightly round but it is normal
for contour and rounded and bilaterally because the patient has oval body
symmetry. symmetrical. physique and chubby body.
6. Inspect umbilicus for
contour, location, Umbilicus is depressed 3rd visit:
signs of inflammation and beneath the On the third visit, the patient's
or hernia. abdominal surface. abdomen contour is slightly
7. Observe for smooth, round, which is normal given the
even respiratory Visible peristalsis is patient's oval body shape and
movements. slowly transverses the chubby body.
8. Observe for surface abdomen in slanting
motions (visible downward movements
peristalsis) as observed in thin
client. Pulsations of the
abdominal aorta are
visible in the epigastric
area in thin clients.
Bowel sounds Auscultation Auscultate the bowel sounds High pitched sounds 1st Visit: The sound of the bowel The bowel sounds of
on the abdominal quadrants heard every 5 to 15 movements is normal in all four the four quadrant is
using the diaphragm of the seconds as intermittent quadrants. The bowel sound is normal.
stethoscope. gurgling sounds in all 4 heard in the ileocecal valve.
4. Begin by placing the quadrants as a result of There is no presence of
diaphragm on the fluid and air movement unnecessary bowel sound in the
RLQ. Listen for a full in GIT. abdomen.
minute to the
frequency and 2nd visit:
character of bowel The sound of the bowel
movements. Bowel sounds should movements is normal in all four
5. Repeat same step always be heard at the quadrants on the second visit. In
proceeding in ileocecal valve. the ileocecal valve, a bowel sound
sequence to RUQ, can be heard. In the abdomen,
 LUQ, and LLQ.
6. Listen at least for 5
minutes before
concluding the
absence of bowel
sounds.
Abdominal Percussion Begin percussion in RLQ,
quadrants move upward to RUQ, cross
over to LUQ, and down to
LLQ. Note when tympani
changes to dullness.
15. NEUROLOGIC SYSTEM
ASSESSMENT OF COMMON DEEP TENDON REFLEX
TYPE ASSESSMENT
4. Flex client’s arm
between 45-degree angle
Biceps and 90 degrees.
5. Place thumb firmly on
there is no unnecessary bowel
sound.
3rd visit: The sound of the bowel
movements is normal in all four
quadrants on the third visit. In the
ileocecal valve, a bowel sound
can be heard. In the abdomen,
there is no unnecessary bowel
sound.
Tympany is heard 1st Visit: The tympany and The tympanic and
because of air in the dullness of the 4 quadrants is dullness sound of the
stomach and intestines. normal. four quadrants is
Dullness is heard over 2nd visit: normal.
organs. The tympany and dullness of the
four quadrants are normal on the
second visit.
3rd visit:
The tympany and dullness of the
four quadrants are normal on the
third visit.
NORMAL REFLEX KEY ANALYSIS AND
FINDINGS INTERPRETATION
1st Visit: The flexion of the The biceps can move freely
There should be biceps is normal and has no sign with no signs of discomfort.
flexion of arm at of discomfort and limitations in
elbow. movement.
 biceps tendon just above
the crease of antecubital 2nd visit:
fossa. The flexion of the biceps is
6. Tap thumb with reflex normal on the second visit, with
hammer. no signs of discomfort or
mobility limits.

Triceps 3. Flex client’s arm at 45
degrees and 90-degree
angle.
4. Tap triceps tendon just
above the elbow.
3rd visit:
The flexion of the biceps is
normal on the third visit, with
no signs of discomfort or
mobility limits.
Extension of elbow 1st Visit: The extension The elbow can move freely.
movement of the elbow is
normal and there are no sign of
discomfort and limitations.
2nd visit:
The elbow extension movement
is normal on the second visit,
and no signs of discomfort or
limits are present.

3rd visit:
The elbow extension movement
is normal on the third visit, and
no signs of discomfort or limits
are present.
3. Flex client’s arm at 45- 1st Visit: The flexion of the The flexion of the forearm is
Brachioradialis degree angle and place Flexion of forearm forearm is normal and has no normal and has no sign of
on lap with the arm sign of discomfort and limitation or discomfort.
semipronated. limitations in movement.
 4. Tap brachioradialis
tendon on thumb side of
the wrist.
3. Ask the client to sit in a
Patellar chair or on edge of bed
with legs hanging freely
or in supine position with
knee flexed.
4. Tap patellar tendon just
below the patella.
3. Ask client to sit with feet
Achilles dangling and partially
dorsiflexed or in a supine
position with legs flexed
at knee and thigh
externally rotated.
4. Tap the Achilles tendon
just above the heel.
2nd visit:
The forearm flexion is normal
on the second visit, with no
signs of discomfort or mobility
restrictions.
3rd visit:
The forearm flexion is normal
on the third visit, with no signs
of discomfort or mobility
restrictions.
1st Visit: The extension The legs can move or extend
Extension of leg movements of the legs are freely without a sign of
below the knee. normal and can move freely. discomfort.
2nd visit:
The leg extension movements
are typical on the second visit,
and the legs can move freely.
3rd visit:
The leg extension movements
are typical on the third visit, and
the legs can move freely.
1st Visit: The foot can move The foot can move normally.
Plantar flexion of freely and no signs of
foot. limitations.
2nd visit:
On the second visit, the foot is
free to move and shows no
evidence of restriction.
 3rd visit:
On the third visit, the foot is
free to move and shows no
evidence of restriction.
3. Position client’s ankle 1st Visit: The bending of the The toes are reacting in the tip
Plantar (Babinski) firmly against the bed. Bending of the toes toes is normal and can bend of the reflex hammer when
4. Slowly stroke client’s downward. easily. The toes are reacting stroking when it touches the
sole with the handle of when a hit it with the reflex soles of the feet. The toes can
the reflex hammer. hammer. move freely or can bend fully
downward.
2nd visit:
The bending of the toes is
normal and can be readily bent
on the second visit. When I hit it
with the reflex hammer, the toes
start to react.

3rd visit:
The bending of the toes is
normal and can be readily bent
on the third visit. When I hit it
with the reflex hammer, the toes
start to react.
 SKILLS IN PHYSICAL ASSESSMENT

ERIKA G. BACARRO

General Description:
Ms. Erika, who is 20 years old youngest daughter of Mr.& Mrs. Bacarro, has brown complexion, black hair and has a mesomorph body type. She’s currently taking her 2nd year in
nursing

VITAL SIGNS
Temperature Respiratory Rate Pulse Rate Blood Pressure Height Weight
st
1 Visit
Date: October 15, 2021 36.4°C 16 breaths per minute 60 beats per minute 120/60 mmHg 152.4 cm 43 kg

2nd Visit
Date: October 30, 2021 36.7°C 16 breaths per minute 60 beats per minute 90/70 mmHg 152.4 cm 42 kg

3rd Visit
Date: October 30, 2021 36.5°C 16 breaths per minute 60 beats per minute 90/80 mmHg 152.4 cm 42 kg

1. SKIN
AREA/FEATUR TECHNIQU NORMAL KEY ANALYSIS AND
E TO ASSESS E SKILLS FINDINGS FINDINGS INTERPRETATION
Color Inspection Inspect variations in skin color Color varies from light 1st Visit: The color and color
under natural sunlight to ensure to ruddy pink or dark The color of skin is fair white, distribution are normal.
accuracy findings. brown, depending on the the color distribution is equal,
race. Color is uniform and has no presence of skin
except for sun exposed lesions, and redness.
areas or normally
lighted pigmented areas 2nd visit:
(nailbeds, palms, lips) in The skin tone is fair white, the
 dark skinned people. color distribution is even, and
there are no skin blemishes or
redness on the second visit.

Lesions Inspection Note for color, size, and
anatomic location and
distribution.
Palpation
Palpate lesions with finger pads
for mobility and contour (flat,
raised, or depressed) and
consistency (soft or durable)
3rd visit:
The skin tone is fair white, the
color distribution is even, and
there are no skin blemishes or
redness on the third visit.
Freckles, skin tags in 1st Visit: The skin has no
elderly, and some types The has no freckles, has 12 presence of lesion, it
of birthmarks and moles normal sizes moles, has no normal seizes of moles
are normal. birthmarks. The contour of skin and the contour of the
is normal and the consistency is skin is normal.
soft.
2nd visit:
The has no freckles, has 12
normal sizes moles, has no
birthmarks. The contour of skin
is normal and the consistency is
soft.

3rd visit:
On the third visit, The has no
freckles, 12 normal-sized
moles, and no birthmarks. Skin
contour is normal, and the
consistency is soft.
Moisture Inspection Note amount and distribution Moisture varies with 1st Visit: The texture and
and activity, body and The skin is moisture, the texture moisture of the skin is
Palpation environmental is smooth and soft. normal.
 temperature, and
humidity in skin folds 2nd visit:
and the axillae. The skin feels moist, and the
texture is smooth and soft on
the second visit.

3rd visit:
The skin feels moist, and the
texture is smooth and soft on
the third visit.
Temperature Palpation Palpate with dorsum of hand Temperature should be 1st Visit: Normal temperature.
noting for uniformity of warmth. uniform and within The temperature is 36.4°C
normal range.
2nd visit:
The temperature is 36.7°C

3rd visit:
The temperature is 36.5°C

AREA/FEATUR NORMAL KEY ANALYSIS AND

E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Texture (quality, Palpation Palpate with finger pads in Texture is not uniform 1st Visit: The thickness of the
thickness, different areas like the palms and soles The soles and palms are soft soles and palms are
suppleness) are thicker than any and the thickness is normal. normal. The texture of
areas. Wrinkled and There are no signs of lesions the palms is soft and
leathery skin in the and wrinkles. the soles is slightly
elderly results from the rough.
normal aging. Process 2nd visit:
with decreased collagen, The soles and palms of the feet
subcutaneous fats, and are soft and normal thickness
sweat glands. on the second visit. Lesions and
wrinkles aren't present.

Mobility and Palpation Assess mobility and turgor to
turgor (elasticity) measure elasticity of skin to
determine the degree of
hydration.
Palpate dependent areas like
the sacrum, feet, and ankles
for mobility by applying
pressure with thumb for 5
seconds. Rate the degree of
edema (accumulation of fluid
in intercellular spaces) by
assessing depth of indention.
Edema may be described on a
scale as follows:
11. 0 = no pitting
12. 1+ = trace/mild
(2mm) pitting
13. 2+ = moderate
(4mm) pitting
14. 3+ = deep/severe
(6mm)
15. 4+ = very
deep/severe
(greater than
8mm)
3rd visit:
The soles and palms of the feet
are soft and normal thickness
on the third visit. Lesions and
wrinkles aren't present.
Absence of indention is 1st Visit: The skin turgor is
dependent areas and the There is no edema and the skin normal and has no sign
resilience of the skin turgor is normal because after of dehydration.
spring back to its doing the test the skin is quickly
previous state after returning back.
being pinched.
2nd visit:
The skin turgor is normal on the
second visit, and there is no
edema. This is because the skin
quickly returns to normal
following the test.
3rd visit:
The skin turgor is normal on the
third visit, and there is no
edema. This is because the skin
quickly returns to normal
following the test.
 Pinch a fold of skin on the
sternal area using forefinger
and note for the spread with
which it returns to place
(turgor).

2. HAIR
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Color and Inspect Assess for color and Color varies from black 1st Visit: The color is black and
Distribution distribution of scalp hair, to pale blonde based on The color of the hair eyelashes, the hair distribution of
eyebrows, eyelashes, and the amount of melanin and eyebrows are pure black. the hair is normal. The
body surface. present. color of the eyebrows,
2nd visit: eyelashes, and the body
Hair, eyelashes, and eyebrows surface are black.
are all pure black on the second
visit.

3rd visit:
Hair, eyelashes, and eyebrows
are all pure black on the third
visit.
Texture and Palpation Assess for the skin’s texture Thin, straight, coarse, 1st Visit: The hair texture and
oiliness and oiliness with the use of thick, or curly. Hair is The hair is oily, thin, shiny and oiliness are normal.
palm. shiny and resilient straight.

2nd visit:
Hair is not oily, thin, shiny, and
straight after the second visit.

3rd visit:
After the third treatment, your
 hair is no longer oily, thin,
shiny, or straight visit.
infestation Inspection Assess for any presence of Free from any 1st Visit: Free from infestations.
infestation by examining the infestation. The hair free from infestations.
hair and scalp.
2nd visit:
The hair was free of bugs on the
second visit.

3rd visit:
The hair was free of bugs on the
third visit.

3. SCALP
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Scaliness and Inspection Part the hair repeatedly all The scalp should be 1st Visit: The scalp is free from
scars over the scalp and inspect for shiny and smooth The scalp is shiny and smooth. scaliness and scars.
scaliness and scars. without lesions, lumps, Has no presence of lesions,
or masses. lumps and masses.

2nd visit:
The scalp is shiny and smooth on
the second visit. There are no
lesions, tumors, or masses
present.

3rd visit:
The scalp is shiny and smooth on
the third visit. There are no
lesions, tumors, or masses
present.
 Tenderness, Palpation Place finger pads on the scalp Absence of redness or 1st Visit: The has no sign of
lesions, lumps, at the front and palpate down scaliness. The scalp is free from redness tenderness and lesions.
masses the midline and each side for and scaliness.
tenderness, lesions, lumps, or
masses. 2nd visit:
The scalp is clear of redness and
scaliness on the second visit.

3rd visit:
The scalp is clear of redness and
scaliness on the third visit.

4. NAILS
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
TO ASSESS
Color, shape, and Inspection Inspect for color and shape Nailbeds is highly 1st Visit: The nails color,
texture vascular with a pink The nails are pink color and the texture and shape are
color in light skinned nailbed are firm and the texture normal.
clients and longitudinal are smooth. The nails are not
streaks of brown or clubbing or spooning.
black pigmentation in
dark skinned clients. 2nd visit:
Palpation Palpate nailbed for firmness Angle between The nails are pink in color on the
and texture fingernail and base is second visit, with a firm nailbed
about 160 degrees. and smooth texture. There is no
spooning or clubbing going on
Nailbed is firm with the nails.

3rd visit:
The nails are pink in color on the
third visit, with a firm nailbed

Capillary refill Palpation Press two or more nails
between thumb and index
finger and note the degree of
blanching and return to
normal color.
Lesions Inspection Inspect the tissue surrounding
nails for lesions.
and smooth texture. There is no
spooning or clubbing going on
with the nails.
When pressure is 1st Visit: The capillary refill is
released from the nail, it The capillary refill is normal normal
promptly returns to its because after doing the exam the
normal color. color of the nail is turning pick
quickly.
2nd visit:
The capillary refill is usual on
the second visit because the
color of the nail changes soon
after the exam.
3rd visit:
Because the color of the nail
changes soon after the exam, the
capillary refill is usually done on
the third visit.
Tissue surrounding the 1st visit: The tissue surrounding The tissue surrounding
nail is intact. the nail are not inflamed and has the nails are normal.
no lesions.
2nd visit:
The tissue surrounding the nail is
not inflamed and there are no
lesions on the second visit.
3rd visit:
On the third visit, the tissue
surrounding the nail is not
 inflamed, and there are no
lesions.

5. SKULL
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Shape and Inspection Inspect skull for shape, Rounded, symmetrical, 1st Visit: The client head
symmetry symmetry, size in proportion normocephalic, and The client head is round, symmetry is normal.
to body and position. upright. symmetrical and normal.

2nd visit:
The client's head is normal,
round, and symmetrical during
the second appointment.

Contour, Masses, Palpation Palpate with fingerpads
Depressions and beginning in frontal area and
Tenderness continuing over parietal,
temporal, and occipital areas
for contour, masses,
depressions, and tenderness.
3rd visit:
The client's head is normal,
round, and symmetrical during
the third appointment.
Smooth, non-tender, 1st Visit: The client has no
free of masses or There is no presence of lesions, presence of lesions,
depressions. free from tenderness, masses and tenderness and masses.
inflammation. The skull contour
is normal.
2nd visit:
On the second visit, no lesions
are present, and there are no
discomfort, lumps, or
inflammation. The shape of the
skull is normal.
 3rd visit:
On the third visit, there are no
lesions and no discomfort,
lumps, or inflammation. The
skull's shape is normal.
6. FACE
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Facial features Inspection Inspect facial features for May be oval, round, or 1st Visit: The facial features are
expression, shape, and square. Symmetrical The face is round and normal.
symmetry of eyebrows, features and movement. symmetrical. The facial
placement of nose, eyes, and movements have no sign of
ears. limitations.

2nd visit:
The face is round and
symmetrical on the second visit.
There are no signs of limits in
the face movements.

3rd visit:
On the third visit, the face is
round and symmetrical. The face
movements show no signs of
limitation.
Edema and Inspection Inspect for any presence of No edema and masses 1st Visit: There is no presence
masses edema and masses No presence of edema and of edema and masses.
masses. It has 12 moles. The The client has normal
color distribution of the skin of sizes of the moles.
the face normal is equal.

2nd visit:
 There was no edema or lumps on
the second visit. It has a total of
12 moles. The usual color
distribution of the skin of the
face is uniform.

3rd visit:
On the third visit, there was no
edema or lumps. It has 12 moles
in total. The color distribution of
the skin on the face is usually
uniform.

7. EYES
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Visual acuity Inspection Test visual acuity. Normal vision based on 1st Visit: The client has normal
15. Position Snellen chart the Snellen chart is 20/20 The visual is 20/20 when the visual acuity. The but
20 ft. in front of client. at the distance of 20 feet client read the letter in 20 feet. the protective lens are
16. Remove corrective the normal eye can read The client has corrective lens for only use when the
lenses, if appropriate. the chart). her stigmatism. The lenses are client is using gadgets.
17. Instruct client to cover also protective lens for But it does not affect
one eye and read lines protecting the eyes for the screen the client visual
starting with top of radiation. acuity. The stigmatism
chart from left to right. of the client does not
18. Note the line where 2nd visit: affect her visual
client reads more than When the customer reads the acuity.
half of the letters. letter from a distance of 20 feet,
19. Record results as a the visual is 20/20 on the second
fraction sc (without visit. For her stigmatism, the
correction), 20/ client wears a corrective lens.
distance number, and The lenses also serve as shields
 the number of the against screen radiation.
letters missed.
20. Repeat same steps for 3rd visit:
the other eye. On the third visit, the visual is
21. If appropriate, repeat 20/20 when the customer reads
steps with patient the letter from a distance of 20
wearing the corrective feet. The client wears a
device. corrective lens because of her
stigmatism. The lenses also
protect against screen radiation.
Inspection Test eye for extraocular Eye movement should 1st Visit: The eye movement is
muscle movements: be symmetrical as both The eye movement is normal.
17. Place the client in eyes follow the direction symmetrical and the eyes of the
sitting position. of the gaze and client follow the object easily
18. Instruct the client to converge on the held while moving.
hold head still. object as its moves
19. Ask the client to toward the nose. 2nd visit:
follow an object with The eye movement is
eyes. symmetrical on the second visit,
20. Move objects with 6 and the client's eyes effortlessly
fields of gaze. follow the object while moving.

3rd visit:
On the third visit, the eye
movement is symmetrical, and
the client's eyes effortlessly
follow the object while moving.
***The 6 Fields of Gaze 1st Visit: Th eye movement in
13. Conjugate left lateral The client is following the object the six fields of gaze is
gaze in 6 fields of gaze easily and has normal and has no
14. Left down and lateral no sign of nystagmus or sign nystagmus.
gaze involuntary movements.
 15. Right down and lateral
gaze 2nd visit:
16. Conjugate right lateral The client is effortlessly
gaze following the item in six fields
17. Right up and lateral of vision on the second visit,
gaze with no signs of nystagmus or
18. Left up and lateral involuntary movements.
21. Observe for parallel The upper eyelids cover
eye movement. only the uppermost part 3rd visit:
22. Pause during upward of the iris and are free On the third visit, the client is
and lateral gaze field from nystagmus effortlessly following the item in
to detect in voluntary (involuntary rhythmical six fields of vision, with no signs
rhythmic oscillation of oscillation of the eyes). of nystagmus or involuntary
eyes. A few beats of movements.
23. Note position of upper nystagmus with extreme
eyelid in relation to lateral gaze can be
the iris and eyelid bag normal.
as the client’s eye
move from up and
down.
24. Move object forward
to about 5 inches in
front of the client’s
nose at the midline
and observe for
convergence, and
record result.
External Inspection Observe upper eyelid. Upper eyelid should 1st Visit: The external features
anatomical overlap iris. The eyelids have no lesion, of the eye are normal.
structures Check eyes and eyelids for edema, There is no presence
inflammation, crusting, Eyes and eyelids should Masses and inflammation. The of lesions, crusting
edema or masses. be free from lacirmal glands are not swelling and edema.

Inspect lacrimal glands and
sacs for swelling.
Palpation Check for blocking of
nasolacrimal duct by pressing
against inner orbital rim of
lacrimal sac.
Inspect duct by palpating on
the lacrimal sac and observing
for regurgitation of fluid.
inflammation, crusting, and the upper eyelids is in
edema or masses. correct position.
2nd visit:
The eyelids have no lesion,
edema, or swelling on the second
visit.
Inflammation and masses. The
lacirmal glands aren't swollen,
and the top eyelids are in the
right place.
3rd visit:
On the third visit, there is no
lesion, edema, or swelling of the
eyelids.
Masses and inflammation The
lacirmal glands are not swollen,
and the upper eyelids are in the
proper position.
Lacrimal gland should 1st Visit: The lacrimal gland is
not be palpable. The lacrimal gland is not not swelling. The tear
palpable and tears are freely is flowing freely in the
Tears flow freely from flowing in the eyes. eyes.
the lacrimal gland over
the cornea and 2nd visit:
conjunctiva to the The lacrimal gland is not
lacrimal duct. perceptible during the second
visit, and tears are freely flowing
in the eyes.
3rd visit:
The lacrimal gland is not
 perceptible during the third visit,
and tears are freely flowing in
the eyes.
Inspection Inspect bulbar and palpebral Bulbar is transparent 1st Visit: The bulbar, palpebral,
conjuctiva and sclera. with small blood The bulbar, palpebral sclera and the pupil of
g. Instruct client to look vessels. conjunctiva and sclera is normal. both eyes are normal.
upward while Palpebral conjunctiva The sclera is color white with
depressing lower lid covering the inside of some blood vessels. The
with thumb. the upper and lower palpebral is moist and has
h. Inspect for color, eyelids is pink and normal color. The corneas are
redness, swelling, moist. shiny, moist and clear. The
exudates, or foreign Sclera is white with diameter of the pupil is normal
bodies. some superficial blood and has black color. When I
i. Inspect cornea, lenses, vessels depending on move my penlight, the pupil is
pupil, iris, and anterior the race. responding normal. The
chamber: conjunctiva is color pink and not
1. Stand in front Corneas are moist, shiny dry.
of the client. and clear.
2. Shine penlight Lenses are transparent. 2nd visit:
directly on Pupils are black, round The bulbar, palpebral
cornea. and equal diameter, conjunctiva, and sclera are
3. Move light ranging from 2-6mm. normal on the second visit. The
laterally and Entire iris should sclera is white in hue and
view cornea illuminate when shining contains some blood veins. The
from that light laterally too palpebral is moist, and the color
angle; note nasally. is normal. The corneas are clear,
color, lustrous, and moist. The pupil
discharge, and has a normal diameter and a
lesions. black color. The pupil responds
4. Look at pupil normally when I shift my
and note size penlight. The conjunctiva is pink
and shape. in color and does not appear to
 5. Shine penlight be dry.
directly on
pupils to assess 3rd visit:
lens and color. On the third visit, the bulbar,
6. Look at iris for palpebral conjunctiva, and sclera
size, and are all normal. The sclera is
ability of white in color and contains
pupils to react blood veins. The palpebral is
to light. moist, and the color is normal.
7. Shine a light The corneas are clear, lustrous,
obliquely and moist. The pupil has a
through normal diameter and is black in
anterior color. When I move my penlight,
chamber from the pupil reacts normally. The
lateral side conjunctiva is pink in color and
toward nasal does not appear to be dry.
side.
Inspection Test for papillary response to Pupils should constrict 1st Visit: The pupils are
light and reaction to quickly in direct The pupil is responding correctly responding correctly
accommodation in dimly lit response to light and the on the light of my penlight. It is when the light of the
room. opposite pupil should constricting when the light is penlight is moving
15. Instruct client to look also constrict. close and dilated when the light away and moving near
straight ahead. Pupil should be equal in is moving far away. The pupils the eyes.
16. Bring penlight from size. are equal in size.
side of the client’s Papillary
face to directly in accommodation causes 2nd visit:
front of the pupil. constriction in response The pupil is responding correctly
17. Note quickness or to objects that are near. under the light of my penlight on
response to light. Pupillary dilatation the second visit. When the light
18. Shine light into same occurs when pupils is close, it constricts, and when
eye observing for accommodate objects at the light is far away, it dilates.
response or pupil for a distance, with The pupils are all the same size.
 equality of size and symmetrical 3rd visit:
repeat steps to the convergence of eyes. On the third visit, the pupil is
other eye. responding correctly under the
19. Instruct client to gaze light of my penlight. It constricts
at your finger held 4-6 when the light is close, and it
inches from her nose dilates when the light is far
then to glance at a away. All of the pupils are the
distant object while same size.
you note papillary
reflex.
20. Move finger toward
the bridge of client’s
nose noting response
of both pupil.
21. Record results
PERRLA (pupils
equal, round, reactive
to light
accommodation).

8. EARS
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
External ear Inspection Examine external ear, called Symmetrical, with upper 1st Visit: The external ears are
the auricle or pinna for attachment at eye corner The ears are symmetrical, in the normal.
placement, symmetry, color, level, and is fleshed right position and skin is equal in
discharge and swelling. colored. the color of the skin.

2nd visit:
On the second visit, the ears are
symmetrical, in the correct
position, and the skin color is

Palpation Palpate the auricle between
the thumb and index finger
noting lesions or tenderness
by moving auricle up and
down, same with the mastoid
tip.
Press inward on tragus noting
any tenderness.
Auditory acuity Inspection The Whispered Voice Test
9. Instruct the client to
occlude one ear with
finger and repeat the
words when heard.
10. Stand 1-2 feet away
from the client, out of
view to avoid client
uniform.
3rd visit:
On the third visit, the ears are
symmetrical, in the correct
position, and the skin color is
uniform.
Firm, smooth, free from 1st Visit: The external ears are
lesions and pain. The ears of the client have no free from lesions and
lesions, tenderness and the has no sign of pain in
texture of the ears smooth. Has the client.
no sign of discomfort.
2nd visit:
On the second session, the
client's ears are free of lesions,
pain, and have a smooth texture.
Hasn't shown any signs of
discomfort.
3rd visit:
On the third session, the client's
ears are free of lesions, pain, and
have a smooth texture. Hasn't
shown any signs of discomfort.
The client should be 1st Visit: The client has normal
able to repeat whispered The heard the word “APPLE” auditory acuity.
words. when it whispered in both ears 1-
2 feet away.
2nd visit:
On the second visit, the phrase
"KEYS" was whispered in both
 from lip reading, and ears from a distance of 1-2 feet.
softly whisper
numbers on side of the 3rd visit:
ears. Increase voice On the second visit, the phrase
volume until client "LAPTOP" was whispered in
identifies uttered both ears from a distance of 1-2
number. feet.
11. Repeat procedure on
other ear.
12. Record results.

9. NOSE AND SINUSES

AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Nose Inspection Inspect the nose for Located symmetrically, 1st Visit: The nose placement is
symmetry, deformity, flaring, midline of the face, and The nose is symmetrical in the normal, has no sign of
or inflammation and discharge is without swelling, midline of the face, free form lesion, swelling and
from the nares. bleeding, lesions, or lesions, swelling and masses. masses.
Test patency of each nostril: masses. The nostrils of the client are
e. Instruct client to close normal.
the mouth and apply Each nostril is patent.
pressure on one nares 2nd visit:
and breathe The nose is symmetrical in the
f. Repeat test on opposite midline of the face on the second
nares. visit, with free form lesions,
swelling, and masses. The
client's nostrils are normal.

3rd visit:
The nose is symmetrical in the
midline of the face on the third
visit, with free form lesions,

Nasal cavities Inspection Inspect the nasal cavity with a
penlight:
g. Tilt client’s head in an
extended position.
h. Place non dominant
hand on client’s head
using your thumb, and
lift the tip of the nose.
i. With the lit penlight,
asses each nostril; and
note for color of
anterior nares, nasal
septum for deviation,
perforation, or
bleeding, and inspect
for swelling and
discharge.
Nasal sinuses Palpation Apply gentle upward pressure
on frontal and maxillary areas
avoiding pressure on the eyes.
Percuss area and note the
sound.
swelling, and masses. The
client's nostrils are normal.
Mucosa is pink or dull 1st visit: My nasal cavities are The nasal cavities are
without swelling or pink and has no swelling and normal.
polyps. discharges. The septum is intact.
Septum is midline and
intact. 2nd visit:
A small amount of clear My nasal cavities are pink on the
watery discharge is second visit, with no swelling or
normal. discharges. The septum is in
good condition.
3rd visit:
On the third visit, my nasal
cavities are pink, with no
swelling or discharges. The
septum is in good shape.
None-tender air filled 1st Visit: The nasal sinuses are
cavities. The nasals sinuses are not not palpable.
swelling and cannot be
inflammable. The resonant
Resonant sound upon sound is normal. Has no sign of
percussion. tenderness and discomfort.
2nd visit:
The nasal sinuses are not
swollen and cannot be inflamed
during the second visit. The
resonance noise is just normal.
There are no indications of

10. Mouth
AREA/FEATUR
E TO ASSESS TECHNIQUE SKILLS
Breath Inspection Stand 12-18 inches in front of
client and smell the breath.
Lips Observe lips for color,
moisture, swelling, lesions
e. Instruct client to open
mouth and use tongue
depressor to retract
buccal mucosa and
note color, hydration,
inflammation, or
lesions.
f. Invert lower lip with
thumbs on inner oral
mucosa and muscle
tone. Repeat procedure
with thumb and index
finger for upper lip.
tenderness or discomfort.
3rd visit:
During the third visit, the nasal
sinuses are not swollen and
cannot become inflamed. The
resonance noise is completely
normal. There is no sign of
tenderness or discomfort.
NORMAL KEY ANALYSIS AND
FINDINGS FINDINGS INTERPRETATION
Breath should smell 1st Visit: The client breath smell
fresh. My breath is no unnecessary is normal and the lip is
smell or unpleasant smell. normal.
The lips and mucosa are pink,
firm and moist. Free from
Lips and mucosa should inflammation and lesions.
be pink, firm, and moist
without inflammation or 2nd visit:
lesions. My breath has no superfluous or
unpleasant odor on the second
visit.
The mucosa and lips are rosy,
firm, and supple. Inflammation
and lesions are absent.
3rd visit:
On the second visit, my breath

Gums Inspection Inspect gums for gingivitis
and note color, edema,
retraction, bleeding and
lesions.
Palpation
Palpate gums with tongue
blade for texture
Ask client to clench teeth to
Teeth Inspection assess position and alignment
with the use of a tongue
depressor, expose molars and
note for tartar, cavities,
extraction and color.
has no superfluous or unpleasant
odor.
The mucosa and lips are rosy,
firm, and supple. Inflammation
and lesions are not present.
Gums are pink, smooth 1st Visit: The gums are normal
and moist. The gums are pink, smooth, firm and firm.
and moist.
2nd visit:
Gums are firm. The gums are pink, smooth,
firm, and moist during the
second visit.
3rd visit:
During the third visit, the gums
are pink, smooth, firm, and
moist.
Teeth are properly 1st Visit: The client has
aligned, smooth, white The client has corrective corrective alignment
and shiny. alignment in the teeth, the sizes (retainer) to adjust the
are normal and the color are spacing of her teeth.
white and shiny. There are no The teeth are normal
presence of cavities and tartar. in color and sizes.
2nd visit:
On the second visit, the client's
teeth are in better alignment, the
sizes are normal, and the color is
white and gleaming. There are

Inspection Instruct client to protrude
tongue:
7. Inspect dorsum of
tongue and note for
color, hydration,
texture, symmetry.
Tongue 8. With penlight, inspect
sides and ventral
surface and note for
Palpation size, texture, nodules,
or ulcerations.
9. Still with penlight,
inspect floor of mouth,
salivary glands, and
duct openings.
Grasp tongue with a gauze
and gently pull it to one side
and palpate full length of
tongue.
no cavities or tartar on the teeth.
3rd visit:
The client's teeth are better
aligned, the sizes are normal,
and the color is white and
gleaming after the third visit.
The teeth are free of cavities and
tartar.
1st Visit: The tongue can move
When protruded, tongue The tongue can move freely, not freely and has no sign
lays midline, medium inflamed, and free from any of discomfort on the
red or pink in color, lesion, has pink color and it is client. The texture of
moist and smooth along moist. The dorsal and ventral the dorsal surface is
lateral margins, with surface texture is normal and no normal and it is free
free mobility. presence of lesions. from lesion.
The dorsal surface is
slightly rough (taste 2nd visit:
buds) and free from The tongue may move easily, is
lesions. not inflamed, and is free of any
The ventral surface is lesions during the second visit. It
highly vascular, smooth, has a pink tint and is moist. The
moist, and free of texture of the dorsal and ventral
lesions. surfaces is normal, and no
lesions are present.
3rd visit:
During the third visit, the tongue
may move freely, is not
inflamed, and is free of lesions.
It is pink in color and moist.
There are no lesions and the
 texture of the dorsal and ventral
surfaces is normal.
Inspection Inspect the soft and hard Palates are concave and 1st Visit: The color of the both
palate with a penlight: pink. Both soft and hard palate is pink palates is normal.
Palate e. Instruct client to Hard palate has ridges. and concave. The hard palate has Each palate has
extend head backward Soft Palate is smooth. ridges and the soft palate is normal characteristics.
and hold mouth open. smooth surface. Free from lesions,
f. Inspect the hard palate 2nd visit: inflammation and any
(roof of mouth) and Both the soft and hard palates abnormalities.
soft palate for color, are pink and concave on the
shape, lesions. second visit. The ridges on the
hard palate are visible, while the
soft palate has a smooth surface.

3rd visit:
Both the soft and hard palates
are pink and concave on the third
visit. The ridges on the hard
palate are visible, while the soft
palate has a smooth surface.
Inspe4ction Inspect pharynx using tongue With phonation, the soft 1st Visit: The sizes of the tonsil
depressor and penlight: palate and uvula rise The pharynx is pink and free are normal and the
Pharynx k. Explain procedure to symmetrically. from any lesions. And the uvula pharynx is normal and
client. The pharynx is pink, is perfectly symmetrical. The free from lesions. The
l. Instruct client to tilt vascular, lesion free. tonsil size is normal they are not uvula vibrations are
head back and open Tonsil size is evaluated inflamed. When the client says normal and it is not
mouth. using the grading scale. the “ah” the uvula position is inflamed and it is
m. With non-dominant normal and not inflamed. intact in the right
hand, place tongue position or in the
depressor on middle 2nd visit: midline.
third of tongue. With The pharynx is pink and free of
the dominant hand, lesions on the second visit. The
 shine light into back uvula is also perfectly
of throat. symmetrical. The tonsils are
n. Instruct client to say normal in size and are not
“ah” and note inflamed. The uvula position is
position, size, normal and not inflamed when
appearance of tonsils the client says "ah."
and uvula.
o. Inform client of 3rd visit:
eliciting gag reflex by The pharynx is pink and free of
touching the posterior lesions on the third visit. The
1/3 of tongue with uvula is also perfectly
tongue blade if palate symmetrical. The tonsils are
and uvula fail to rise normal in size and are not
symmetrically with inflamed. The uvula position is
phonation. normal and not inflamed when
the client says "ah."

11. NECK
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Inspection Instruct client to: Muscles are 1st Visit: The neck movements
Symmetry and e. Flex chin to chest and symmetrical with head The neck can move freely and in are normal and has no
Musculature to teach side and in central position. full range of motion. The muscle sign of discomfort and
shoulder to test Movement though full is symmetrical and the client has pain.
anterior range of motion without no complaint of discomfort.
sternocleidomastiod complaint of discomfort
muscle. or limitation. 2nd visit:
f. Hyperextend the neck On the second visit, the neck is
backward to test free to move and has a full range
posterior trapezia. of motion. The muscle is
symmetrical, and the client
reports no discomfort.

Palpation Palpate lymph nodes and
instruct client to relax and flex be palpable. Small,
neck slightly forward.
7. Stand in front of seated insignificant.
Lymph nodes client.
8. Methodically palpate
both sides of face and
neck simultaneously
with gentle pressure,
move pads and tip of
middle three fingers in
small circular motion.
Follow a systematic
sequence in palpating
the lymph nodes.
9. Note size, shape,
mobility, consistency
and tenderness.
Trachea Inspection Note for position.
Palpation Place thumbs and index finger
on sides of trachea and apply
gentle pressure and palpate.
3rd visit:
The neck is free to move and has
a full range of motion on the
third visit. The muscle is
symmetrical, and the client is not
in pain.
Lymph nodes should not 1st Visit: The lymph nodes are
The lymph nodes are palpable, normal.
movable nodes are the mobility and size are normal.
2nd visit:
The lymph nodes are palpable on
the second visit, and their
mobility and size are normal.
3rd visit:
The lymph nodes are palpable on
the third visit, and their mobility
and size are normal.
Midline position above 1st Visit: The trachea of the
the suprasternal notch. The trachea is normal, the client is normal.
position is in the midline and has
no presence of discomfort when
palpating it.
2nd visit:
 The trachea is normal on the
second visit, with the position in
the midline and no discomfort
when palpated.

3rd visit:
The trachea is normal on the
third visit, with the position in
the midline and no discomfort
when palpated.
Palpation With client seated , Thyroid cannot be 1st Visit: The client did not
assessment may be done with visualized. The thyroid cannot be show any insignificant
posterior and anterior visualized. The client did show reaction when
Thyroid approach: It may or may not be any discomfort, free from palpating the thyroid
felt. tenderness and it is not inflamed area of the neck.
E. POSTERIOR and bulging. There is no
APPROACH If felt, it should be presence of unnecessary sounds.
1. Stand behind client smooth, soft, non tender The client can swallow properly.
and place thumbs on and not enlarged.
nape of neck and 2nd visit:
bring fingers On the second visit, the thyroid
interiorly around cannot be seen. The client did
neck with their tips not express any discomfort, it
resting over tracheal was not tender, and it was not
rings. inflamed or bulging. There are
2. Ask client to tilt no unnecessary sounds. The
chin forward to client can swallow properly.
relax neck muscles
and swallow. 3rd: visit:
3. Palpate the isthmus The thyroid cannot be seen on
rise under fingers the third visit. The client
and feel each lateral expressed no discomfort, it was
 lobe before and not tender, it was not inflamed,
while client and it was not bulging. There are
swallow. no extraneous sounds. The client
4. Ask client to flex is able to swallow properly.
forward and to left,
and displace thyroid
cartilage to right
with tips of left
fingers. Note any
bulging of gland.
5. Press fingers of left
hand against left
side of thyroid
Auscultation cartilage to stabilize
it while palpating
with the fingers of
right hand while
client swallows.
6. Note consistency,
nodularity, or
tenderness as gland
moves upward.
7. Repeat steps to
opposite side.
F. ANTERIOR APPROACH
1. Stand in front of the
client.
2. Instruct client to tilt
chin forward and
place right thumb on
thyroid cartilage and
displace cartilage to
 the right.
3. Grasp elevated
displaced right lobe
with thumb and
fingers of left hand
and palpate for
consistency,
nodularity or
tenderness as client
swallows.
4. Repeat steps to
opposite side.

If gland appears enlarged,

place the bell of the
stethoscope over gland and
listen for vascular sounds such
as soft, rushing sound, or
bruit.

12. THORAX and LUNGS

AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Inspection Place client in sitting position Respirations are quiet, 1st visit: The breathing pattern is The breathing of the
with arms folded across chest, effortless, and regular, normal and it has 16 breaths per client is normal and
back exposed. with 12-20 breaths per minutes. The thorax is unison on the client can breathe
5. Assess shape and minute. the respiratory cycle. The shape easily. The shape and
Shape, symmetry, symmetry by taking Thorax rises and falls in and size when have a breathing movement are normal.
and diameter note of the rate and unison with respiratory movement is normal and The thorax is unison in
rhythm of respirations, cycle. symmetrical. the movement of the
movement of chest Ribs slope across and respiratory cycle.
wall with deep down, without 2nd visit:
 inspiration and full movement or bulging in The breathing pattern is normal
expiration. the intercostals spaces. on the second visit, with 16
6. Estimate breaths per minute. On the
anteroposterior respiratory cycle, the thorax
diameter in proportion moves in unison. When there is a
to lateral diameter. breathing movement, the shape
and size are normal and
symmetrical.

3rd visit:
The breathing pattern is normal
on the second visit, with 17
breaths per minute. On the
respiratory cycle, the thorax
moves in unison. When there is a
breathing movement, the shape
and size are normal and
symmetrical.
Lesions Palpation 9. Palpate for lesions or Thumb should separate 1st visit: The posterior thorax There are no presence
areas of pain. an equal distance of 3- has no sign of discomfort when of lesions and no sign
10. Palpate thoracic 5cm and in the same palpating and it shown that the of discomfort and
th
expansion at 10 rib by direction during thoracic client is free from tenderness, pain. The vibrations in
placing thumb close to expansion and meet in lesions and pulsations. The client the chest are normal
client’s spine and the midline on has normal vibrations while and has no sign of
spread hands over expiration. speaking the “99” word. There is abnormalities.
thorax. Note no other cause of abnormal
divergence of thumbs; Posterior thorax is free vibrations. The thoracic
feel for range and from tenderness, lesions expansion is normal and has no
symmetry of and pulsations. other abnormal shapes and
movement during deep movements.
inhalation and full Fremitus is equal on
exhalation. both sides of thorax, 2nd visit:
 11. Place ulnar aspect of strongest at the level o9f On the second visit, there is no
open hand at right tracheal bifurcation. sign of discomfort when
apex of lung and place palpating the posterior thorax,
hand at each posterior and the client is free of
thorax location. Then tenderness, lesions, and
instruct client to say pulsations. While saying the
“99” and palpate for word "BB," the client
tactile fremitus experiences normal vibrations.
(vibrations caused by There is no other explanation for
vibrations). Note areas abnormal vibrations. The
of increased and thoracic expansion is normal,
decreased fremitus. and no other abnormal shapes or
12. Move hands from side movements are present.
to side, from light to
left with client 3rd visit:
repeating the words On the third visit, there is no
with the same intensity sign of discomfort when
every time hands are palpating the posterior thorax,
placed on the back. and the client is free of
tenderness, lesions, and
pulsations. While saying the
word "JUICE," the client
experiences normal vibrations.
There is no other explanation for
abnormal vibrations. The
thoracic expansion is normal,
and no other abnormal shapes or
movements are present.

5. Start at lung apices by Air filled lungs create a 1st visit: The sound when The sound when
moving hands from resonant sound. percussion the lungs is normal. percussion the lungs is
Sound Percussion side to side across the normal.
 top of each shoulder. 2nd visit:
Note sound produced The sound of percussion on the
from each percussion Identify contralateral lungs is normal on the second
strike and compare sound; bones create flat visit.
with contralateral sound. Thorax is more
sound. resonant in children and 3rd visit:
6. Continue downward thin adults. Percussion on the lungs is
and post lateral every normal on the third visit.
other intercostals
space. Note intensity,
pitch, duration, and
quality of percussion.
9. Place diaphragm of Posterior sound: 1st visit: The breath sounds of The breathing sound
Auscultation stethoscope on right vesicular and the patient is normal and has no of the client is normal.
lung apex. Instruct bronchovesicular. presence of wheezing sounds or
client to inhale and unnecessary when the
Breath sounds exhale deeply and Lateral sound: vesicular respiratory cycle.
slowly when
stethoscope is felt on A large chest will 2nd visit:
the back. Repeat on produce decreased On the second visit, the patient's
left lung apex. breath sound. breath sounds are normal, with
10. More downward every no wheezing or unnecessary
other intercostals sounds during the respiratory
spaces and auscultate, cycle.
placing stethoscope in
the same position on 3rd visit:
both sides. On the third visit, the patient's
11. Auscultate lateral breath sounds are normal, with
aspect by placing no wheezing or unnecessary
stethoscope directly sounds during the respiratory
below right axillae cycle.
instructing client to
 breath only through
the mouth and to
inhale and exhale
deeply and slowly.
Proceed downward on
every other intercostals
space on the same side.
12. Repeat last step on the
left side.

B. ANTERIOR THORAX
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATIO
N
Inspection Place client in sitting position Thorax rises and falls in 1st visit: The thorax of the client The symmetry,
or supine position. Inspect unison with respiratory is normal in size and unison in the rhythm and slope are
Symmetry, client’s chest for: cycle, ribs at 45-degree movement of the respiratory normal.
rhythm and slope 5. Symmetry and depth angle with sternum. cycle.
of movement. Inspiratory breath 2nd visit:
6. Slope of ribs and sounds are not audible at The client's thorax is normal in
musculoskeletal a distance of more than size and moves in unison with the
deformities. 2to 3 cm from mouth. respiratory cycle on the second
visit.

3rd visit:
The client's thorax is normal in
size and moves in unison with the
respiratory cycle on the third
visit.

Tenderness, Palpation 7. Place fingerpads on Same normal findings 1st visit: There is presence of
pulsation, masses right apex above the with posterior palpation. There are no presence of lesion, abnormal findings.
and crepitance clavicle. Proceed masses and respiratory movement The respiratory
downward to each rib when inhaling and exhaling is movements is normal.
and intercostals space normal. The expansion of the
and note for lungs when inhaling is normal.
Respiratory tenderness, pulsation,
excursion masses and crepitance. 2nd visit:
Repeat on left side. On the second visit, there is no
8. Assess respiratory evidence of a lesion or masses,
excursion by placing and respiratory movement when
thumbs along each inhaling and exhaling is normal.
costal margin with The expansion of the lungs during
Tactile Fremitus hands on lateral rib inhalation is normal.
cage. Instruct client to
inhale deeply; note for 3rd visit:
divergence of thumbs On the third visit, there is no
on expansion; feel evidence of a lesion or masses,
range and symmetry of and respiratory movement when
respiratory movement. inhaling and exhaling is normal.
9. Palpate for tactile The expansion of the lungs during
fremitus. Gently inhalation is normal.
displace female breasts
as necessary.
Percussion Percuss anterior surface by: Resonant sound over 1st visit: The resonant sound of The percussion sound
3. Percuss 2-3 strikes lung tissue the lungs is normal. The in the lungs is
along right lung apex (hyperresonance in breathing sound is normal. The normal.
and repeat on left lung children and thin adults) breath movements are
apex. Proceed Cardiac, liver, and symmetrical and the breath sound
downward, percussing gastric silhouettes emit in the mouth is normal.
in every ICS going dull sound.
from right to left in Ribs emit flat sound. 2nd visit:
same positions on both The resonant sound of the lungs
sides. is normal on the second visit. The
 sound of breathing is normal. The
Assess each thorax area: movements of the breath are
Symmetry and 9. Resonant lung filled. symmetrical, and the sound of the
sound 10. Cardiac dullness: 3rd- breath in the mouth is normal.
5th ICS left of sternum.
11. Liver dullness: place 3rd visit:
finger parallel to upper On the third visit, the resonant
border of expected sound of the lungs is normal.
Auscultation liver dullness in right Breathing sounds are normal.
midclavicular line; Breathing movements are
percuss downward. symmetrical, and the sound of the
12. Gastric air bubble: breath in the mouth is normal.
repeat procedure done
on liver dullness on the
left side.

Auscultate anterior surface by

instructing client to breath
through the mouth and
compares symmetrical areas
of lungs from above
downward:
7. Listen to breath sounds
and note intensity and
identify variations
from normal.
8. Identify any added Anterior sounds:
sounds by location on bronchial,
chest wall and time in bronchovesicular,
the respiratory cycle. vesicular.
9. If breath sounds are A large chest will
diminished, ask client produce decreased
 to breath hard and fast breath sounds.
with mouth open.

13. CARDIOVASCULAR
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Palpation 3. Compress the radial artery Normal Heart rate 1st visit: The pulse rate is in
with your index finger and The pulse rate of the client is 60 normal range.
Arterial Pulses middle finger. beats per minute.

2nd visit:
The client's pulse rate is 60
beats per minute during the
second visit.

3rd visit:
The client's pulse rate is 60
beats per minute during the
third visit.

Inspection Precordial Movement 1st visit: There is no sign of

15. Position the patient The precordial movements are murmur or S3 and S4
supine with the head normal. The sound of the heart sounds. The movements
Heart slightly elevated has a single s1 and s2. is normal.
16. Always examine from
the patient’s right side. 2nd visit:
17. Palpate for point of The precordial movements are
Palpation maximal impulse. normal on the second visit. The
(normally located at 4th or heart sound has a single s1 and
fifth ics, lmcl) s2 note.
18. Listen with diaphragm
 Auscultation at the right 2nd ICS 3rd visit:
19. Listen 2nd ICS near The precordial movements are
sternum. normal on the third visit. The
20. 3rd, 4th, 5th ICS near heart sound has a single s1 and
sternum s2 note.
21. Listen for apex
Palpation Perform the Allen Test to 1st visit: The tissues perfusion is
determine patency of radial The palm color is pink before normal.
and ulnar arteries. Instruct doing tissue perfusion. When
client to rest hands on lap. the radial and ulnar are being
Tissue perfusion 11. Compress both the Palms should turn pink compress the hand turn white
radial and ulnar promptly. and after releasing the hand it
arteries. turns pink again.
12. Firmly compress
arteries and instruct 2nd visit:
client to open hand. Before doing tissue perfusion on
13. Note color of palms. the second visit, the palm color
14. Release one artery is pink. When the radial and
and note the color of ulnar tendons are compressed,
palm. the hand turns white, and when
15. Repeat steps on they are released, the hand
other artery on the returns to pink.
same hand.
3rd visit:
Before doing tissue perfusion on
the third visit, the palm color is
pink. When the radial and ulnar
tendons are compressed, the
hand turns white, and when they
are released, the hand returns to
pink.
14. ABDOMEN
AREA/FEATUR NORMAL KEY ANALYSIS AND
E TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATIO
N
Generalized Inspection Placing client in supine Contour is flat or 1st visit: The contour of the The contour of the
appearance of position with knees flexed over rounded and bilaterally abdomen is flat because the client abdomen is normal
abdomen a pillow, hands at side or over symmetrical. has slim body physique. The and has no sign of
the chest, undrape patient from movement of abdomen is normal. abnormal or
xiphoid process to symphysis Umbilicus is depressed The umbilicus is normal. unnecessary
pubis to expose abdomen. and beneath the movements.
9. Inspect abdomen abdominal surface. 2nd visit:
from rib margin to Because the client has a slim
pubic bone and note Visible peristalsis is body physique, the contour of the
for contour and slowly transverses the abdomen is flat on the second
symmetry. abdomen in slanting visit. The abdominal movement is
10. Inspect umbilicus for downward movements normal. The umbilicus is
contour, location, as observed in thin perfectly normal.
signs of inflammation client. Pulsations of the
or hernia. abdominal aorta are 3rd visit:
11. Observe for smooth, visible in the epigastric Because the client has a slim
even respiratory area in thin clients. body physique, the contour of the
movements. abdomen is flat on the third visit.
12. Observe for surface The abdominal movement is
motions (visible normal. The umbilicus is
peristalsis) perfectly normal.
Bowel sounds Auscultation Auscultate the bowel sounds High pitched sounds 1st visit: There is unnecessary
on the abdominal quadrants heard every 5 to 15 The sound of the bowel sound in the bowel
using the diaphragm of the seconds as intermittent movements is normal in all four movements of the
stethoscope. gurgling sounds in all 4 quadrants. client.
7. Begin by placing the quadrants as a result of
diaphragm on the fluid and air movement 2nd visit:
 RLQ. Listen for a full in GIT. The sound of the bowel
minute to the movements in all four quadrants
frequency and is normal on the second visit.
character of bowel
movements. Bowel sounds should 3rd visit:
8. Repeat same step always be heard at the The sound of the bowel
proceeding in ileocecal valve. movements in all four quadrants
sequence to RUQ, is normal on the third visit.
LUQ, and LLQ.
9. Listen at least for 5
minutes before
concluding the
absence of bowel
sounds.
Abdominal Percussion Begin percussion in RLQ, Tympany is heard 1st visit: The abdominal
quadrants move upward to RUQ, cross because of air in the The tympany and dullness of the quadrants are normal.
over to LUQ, and down to stomach and intestines. 4 quadrants is normal. The sounds are
LLQ. Note when tympani Dullness is heard over normal after the four
changes to dullness. organs. 2nd visit: quadrants percuss.
The tympany and dullness of the
four quadrants are normal on the
second visit.

3rd visit:
The tympany and dullness of the
four quadrants are normal on the
third visit.

15. NEUROLOGIC SYSTEM

ASSESSMENT OF COMMON DEEP TENDON REFLEX
 TYPE ASSESSMENT NORMAL REFLEX KEY ANALYSIS AND
FINDINGS INTERPRETATION
1. Flex client’s arm 1st visit: The client can move the
between 45-degree angle There should be The flexion of the biceps is biceps freely and in full range
Biceps and 90 degrees. flexion of arm at normal and can move in full of motion or full flexion.
2. Place thumb firmly on elbow. range in motion. There are no sign of
biceps tendon just above discomfort and limitations.
the crease of antecubital 2nd visit:
fossa. The flexion of the biceps is
3. Tap thumb with reflex normal on the second visit, and
hammer. it can move through its full
range of motion.

Triceps 1. Flex client’s arm at 45
degrees and 90-degree
angle.
2. Tap triceps tendon just
above the elbow.
3rd visit:
On the third visit, biceps flexion
is normal, and it can move
through its entire range of
motion.
Extension of elbow 1st visit: The movements in the triceps
The extension movement of the are normal. There is no sign
elbow is normal. of discomfort and pain in the
client.
2nd visit:
The elbow extension movement
is normal on the second visit.

3rd visit:
On the third visit, the elbow
extension movement is normal.
1. Flex client’s arm at 45- 1st visit: The flexion in the forearm of
Brachioradialis degree angle and place Flexion of forearm The flexion of the forearm is the client is normal and show
on lap with the arm normal. the full movements of flexion.
semipronated.
2. Tap brachioradialis 2nd visit:
tendon on thumb side of The forearm flexion is normal
the wrist. on the second visit.

1. Ask the client to sit in a
Patellar chair or on edge of bed
3rd visit:
On the third visit, the forearm
flexion is normal.
1st visit: The leg can move freely and
Extension of leg The extension movements of the there is no sign of limitations.