1.

General appearance:

 Affect/behaviour/anxiety
 Level of hygiene
 Body position
 Patient mobility
 Speech pattern and articulation

2. Vital Signs

3. Skin, hair, and nails:

 Inspect for lesions, bruising, and rashes.

 Palpate skin for temperature, moisture, and texture.
 Inspect for pressure areas.
 Inspect skin for edema.
 Inspect scalp for lesions and hair and scalp for presence of lice and/or nits.
 Inspect nails for consistency, colour, and capillary refill.

Abnormal findings include: Uneven hair distribution, color abnormalities (Pallor, Cyanosis, Erythema),
extremes in temperature or moisture of skin, decreased skin turgor, lesions

4. Head and neck:

 Inspect eyes for drainage.

 Inspect eyes for pupillary reaction to light.
 Inspect mouth, tongue, and teeth for moisture, colour, dentures.
 Inspect for facial symmetry.

Abnormal findings include: Tenderness, swelling, asymmetry

Neck Abnormal findings include:  Deviation of the trachea, enlarged thyroid gland or lymph nodes

5. Eyes

Abnormal findings include: Discharge, lesions, redness, no PERRLA

6. Nose and Sinuses

Abnormal findings include: Deviated septum, nasal polyps, discharge

7. Ears

Abnormal findings include: Discharge, lesions, abnormal light reflection on tympanic membrane, scarring
of the tympanic membrane.

8. Mouth and Throat

Abnormal findings include: Swelling, asymmetry, lesions, cyanosis, dry/cracked lips, cleft lip,
discoloration, dryness, hairy tongue, enlarged tonsils, cleft palate.

9. Chest:

 Inspect:
o Expansion/retraction of chest wall/work of breathing and/or accessory muscle use
o Jugular distension

 Auscultate:
o For breath sounds anteriorly and posteriorly
o Apices and bases for any adventitious sounds

o Apical heart rate

 Palpate:
 o For symmetrical lung expansion

Cardiovascular 
Abnormal findings include: Pericardial friction rub, murmur, presence of S3 or S4, irregular heart beat.

Respiratory 
Abnormal Findings include: Retraction, labored breathing, asymmetrical chest expansion Retraction,
gasping for air, Bradypnea or Tachypnea, absent lung sounds, crackles, wheezes, Stridor, and Pleural
friction rub.

10. Abdomen:

 Inspect:
o Abdomen for distension, asymmetry
 Auscultate:
o Bowel sounds (RLQ)
 Palpate:
o Four quadrants for pain and bladder/bowel distension (light palpation only)
 Check urine output for frequency, colour, odour.
 Determine frequency and type of bowel movements.

Abnormal findings include: Abnormal pulsations, Hypo/Hyperactive Bowel sounds, purple or dark red skin
pigmentation, tenderness, mass/protrusion.

11. Peripheral Vascular

Abnormal findings include: Delayed capillary refill, bounding or absent pulses, presence of Arterial or
Venous Disease, skin discolorations. 

12. Neurological & Musculoskeletal

Abnormal findings include: Crepitus, swelling , pain/tenderness, limited or no range of motion, hyperactive
response, pain, tenderness, no response, hyperactive response.

I. Head
a. History (from Review of Systems): Unusually frequent or severe headaches, head injury, dizziness, vertigo
b. Inspection: General size and contour
c. Palpation: Deformities, lumps, or tenderness
II. Face
a. Inspection: Facial expression, Color and texture (especially at mouth* and earlobes), Symmetry of
structures, Involuntary movements, Edema
I. Eyes
a. History (from Review of Systems): Decreased acuity, blurring, blind spots, eye pain, diplopia, redness or
swelling, watering or discharge, glaucoma, cataracts
- Wears glasses or contacts, last eye exam or glaucoma test, how coping with loss of vision if any

Inspection: Eyebrows, eyelids, and eyelashes for abnormalities

- Sclera and conjunctiva for color, swelling, or lesions
- Pupils (equal, round, reactive to light and accommodation)*
- Eye movement (extraocular muscles)*
b. Other tests: i. Snellen eye chart ii. Confrontation test (peripheral vision)

Cranial Nerves
i. II – Optic: Confrontation Test
 ii. III, IV, VI – Oculomotor, Trochlear, Abducens: PERRLA, extraocular movements in six cardinal
positions*
iii. V – Trigeminal: Light touch on forehead, cheek, and chin
iv. VII – Facial: Symmetry when smiling, frowning, closing eyes tightly, lifting eyebrows, and puffing
cheeks
v. VIII – Acoustic: Whisper test
vi. IX, X – Glossophyarngeal, Vagus: Inspect movement of uvula for rise during phonation
vii. XI – Spinal accessory: head rotation and shoulder shrug against resistance
viii. XII – Hypoglossal: Stick out tongue (midline)

NORMAL FINDINGS
Skull
 Generally round, with prominences in the frontal and occipital area. (Normocephalic).
 No tenderness noted upon palpation.
Scalp
 Lighter in color than the complexion.
 Can be moist or oily.
 No scars noted.
 Free from lice, nits, and dandruff.
 No lesions should be noted.
 No tenderness or masses on palpation.
Hair
 Can be black, brown or burgundy depending on the race.
 Evenly distributed covers the whole scalp
 No evidence of Alopecia
 Maybe thick or thin, coarse or smooth.
 Neither brittle nor dry.
Eyebrows
 Symmetrical and in line with each other.
 Maybe black, brown or blond depending on race.
 Evenly distributed.
Eyes
 Evenly placed and inline with each other.
 None protruding.
 Equal palpebral fissure.
Eyelashes
 Color dependent on race.
 Evenly distributed.
 Turned outward.
Mouth
 With visible margin
 Symmetrical in appearance and movement
 Pinkish in color
 No edema
 Moves smoothly no crepitous.
 No deviations noted
 No pain or tenderness on palpation and jaw movement.

Neck
 The neck is straight.
 No visible mass or lumps.
 Symmetrical
 No jugular venous distension (suggestive of cardiac congestion).
 The neck is palpated just above the suprasternal note using the thumb and the index finger.
 The trachea is palpable.
 It is positioned in the line and straight.
 Lymph nodes are palpated using palmar tips of the fingers via systemic circular movements.
Describe lymph nodes in terms of size, regularity, consistency, tenderness, and fixation to
surrounding tissues.