BODY INTERPRET

METHODS FINDINGS RATIONALE

PARTS ATION
- Head is Naturally, the normal head shape
symmetrically when viewed from above should
Inspection rounded with no look similar to an egg, slightly
lesions and wider at the back than the front.
infestations NORMAL
Head
- No presence of Normal head appearance has no
tenderness or lesions and tenderness and no
Palpation masses. signs of abnormalities around the
head
- Hair color is Healthy scalp should be clear of
black with gray flakes and irritation or redness,
strands. and it should be free of dryness, or
Scalp and
Inspection - Scalp is clean, any signs of infection, or
Hair NORMAL
Palpation free from disruption of the skin on the
masses, lumps scalp.” Any itchiness, irritation or
and dandruff. burning sensations might be signs
- Thin hair of an unhealthy scalp.
- No presence of The face is symmetric or slightly
Inspection abnormalities asymmetric; palpebral fissures
equal in size; symmetric
Face NORMAL nasolabial folds.
- No presence of The face of the client appeared
tenderness or smooth and has uniform
Palpation consistency and with no presence
masses.
of nodules or masses.
- Skin in both Normal eyes have eyelashes point
eyelids is outwards and the eyelids will open
without redness, and close easily. The white part of
swelling, or the eye, the sclera, with the
lesions. overlying conjunctiva, is not red
Eyes Inspection - Eyeballs are NORMAL and inflamed. The cornea is bright
symmetrically and clear. The pupil is black and
aligned round. If the pupil and iris are
- Conjunctiva is well seen, this confirms that the
clear cornea must be clear. The
conjunctiva is smooth
- No masses or Normal eyes have no bulging or
bulging masses and there’s no indication
Palpation NORMAL
or exophthalmos or bulging in the
eyes.
 - Ears are equal in Many variations in size and shape
size exist within the label of "normal
ear", but in general, the normal
ear is one which all the structures
Inspection NORMAL (helix, antihelix, tragus,
antitragus, scaphoid/triangular
Ears fossa, and external auditory
canal) are all present and well
formed.
- No masses Normal ears upon palpations are
Palpation NORMAL free from tenderness, lesions and
masses.
- Normal breaths Normal findings might be
in both nostrils. documented, nose is symmetrical
No presence of with no discoloration, swelling or
malformations. Nasal mucosa is
discharge and
pinkish red with no
tenderness. discharge/bleeding, swelling,
Inspection - Frontal and malformations or foreign bodies.
Nose
Palpation maxillary sinuses NORMAL No sinus pain noted. Nose is
Percussion are non-tender to patent with good air flow.
palpate
- Sinuses are non-
tender to
percuss.

- Positive pale lips White or pale lips are often

and mucosa accompanied by general paleness
Due to Chronic affecting the face, lining of the
Mouth
Inspection Kidney eyes, inside of the mouth, and the
Disease nails.

- No masses on Upper and lower gums. They

tongue and gums should appear symmetrical, moist
and pinkish, with well-defined
margins. Dark-skinned people
may have a melanotic line along
Palpation NORMAL
the gum margin. And healthy
dorsal tongue is symmetrical,
pink, moist, and slightly rough
from the papillae, possibly with a
thin, whitish coating.
- Neck is The trachea should be midline,
Inspection symmetric NORMAL and there should not be any
Neck
- Normal neck noticeable enlargement of lymph
 movement nodes or the thyroid gland with
- Prominent neck normal range of motion.
vessels
- No masses or Lymph nodes, if palpable, should
Palpation lumps NORMAL be round and movable and should
not be enlarged or tender
- No masses upon Upon palpation normal bilateral
Breast and palpation. breasts are symmetrical, no
Palpation tender, no suspicious masses, skin
Axillary NORMAL
or nipple changes or
lymphadenopathy.
- Symmetrical Side to side symmetric chest
respiratory effort shape. Distance from the front to
without uses of the back of the chest (anterior-
accessory posterior diameter) less than the
Inspection
size of the chest from side to side
muscle.
(transverse diameter
- Positive dyspnea
and cough
- No tenderness, Is used to evaluate the symmetry
pain and unusual and extent of thoracic movement
sensation. during inspiration. Is usually
Palpation symmetrical and is at least 2.5
Thorax Due to Chronic centimeters between full
(Anterior and Kidney expiration and full inspiration
Posterior) Disease
- There is The bronchial breath sounds over
resonance upon the trachea has a higher pitch,
percussion. louder, inspiration and expiration
Percussion
are equal and there is a pause
between inspiration and
expiration.
- Upon There is high-pitched whistling
auscultation, sound that happens when
Auscultation there is positive breathing through swollen,
dyspnea and constricted airways. It most often
occurs during exhalations.
cough
- Normal Resonant percussion note: heard
resonance over over a normal air-filled lung. Dull
Percussion lung tissue. percussion note (the sound heard
Lungs
Due to Chronic over solid tissues)
(Anterior/Post
Kidney
erior) - Positive rales Absence of loud, high-pitched
Disease
both lungs bronchial breath sounds over the
Auscultation
- SLE Systemic trachea. Medium pitched
bronchovesicular sounds over the
 lupus mainstream bronchi, between the
erythematosus scapulae, and below the clavicles.
- SCIIC retraction Soft, breezy, low-pitched vesicular
breath sounds over most of the
peripheral lung fields.
- The apical pulse The external chest is normal in
is visible appearance without lifts, heaves,
Inspection or thrills. PMI is not visible and is
palpated in the 5th intercostal
space at the midclavicular line
- Upon palpation Palpation includes assessing the
there is no arterial pulse, measuring blood
vibrations pressure, palpating any thrills on
Heart the chest, and palpating for the
Due to Chronic point of maximal impulse. Arterial
(Precordium), Palpation
Kidney pulse: When palpating the arterial
Anterior
Disease pulse, the examiner should be able
Chest
to gather the rate, rhythm, and
characteristics.
- AP tachycardic Normal S1 and S2, with regular
- Positive rate and rhythm. S2 > S1 at the
murmurs base, S1 > S2 at apex. No splitting
Auscultation of the heart sounds heard. No
- PMI Point of
maximal impulse murmur.
at 6th LMCL
Abdomen - Smooth skin Abdomen is soft, symmetric, and
without lesions non-tender without distention.
Inspection NORMAL There are no visible lesions or
scars.
Auscultation - Gurgling bowel Due to Chronic Abdomen is soft, symmetric, and
sound every 5-10 Kidney non-tender without distention.
minutes Disease There are no visible lesions or
- Positive fluid scars.
wave
- Flabby
consistence
 - Tympanic sound The anterior gas-filled abdomen
over air-filled normally has a tympanic sound to
stomach/intestin percussion, which is replaced by
al section. dullness where solid viscera, fluid,
Percussion or stool predominate. The flanks
are duller as posterior solid
structures predominate, and the
right upper quadrant is somewhat
duller over the liver.
- No tenderness Abdomen is soft, symmetric, and
Palpation and masses non-tender without distention
- Rounded contour Flat or rounded contour
Inspection - No visible (protuberant in children until age
lesions 4)
- Absence of pain, Normal findings should include no
Genitourinary tenderness and NORMAL pain, tenderness and mass upon
mass palpation. In addition, during
Palpation palpation patient shall not
- No urgency,
frequency or complain of any urgency or
retention retention to urinate
- Symmetric and Extremities are atraumatic in
equal in length. appearance without tenderness or
Inspection deformity. Extremities are without
swelling or erythema. Full range
of motion is noted to all joints.
Extremities
- No lesions and NORMAL The bone pokes through the skin
(Upper)
masses and can be seen, or a deep wound
- Capillary refill exposes the bone through the skin.
Palpation
(3 seconds) Closed fracture (also called
simple fracture). The bone is
broken, but the skin is intact.
- Symmetric and Extremities are atraumatic in
equal in length. appearance without tenderness or
- No signs of deformity. Extremities are without
edema swelling or erythema. Full range
Inspection
- Veins are Due to Chronic of motion is noted to all joints.
(Lower) prominent Kidney
- Pale palms and Disease
sinuses
- Sutured skin is No signs of deformities and
Palpation present. lesions in extremities

Skin Inspection - Temperature: NORMAL Normal skin color varies from

36.7°C white to pink, and to yellow,
 brown, and black. In the different
ethnic groups, there are
pronounced variations in skin,
head hair, and body hair.
- Absence of Skin temperature is the
lesions and temperature of the outermost
masses on the surface of the body. Normal
surface of the human skin temperature on the
Palpation skin and warm to trunk of the body varies between
touch. 33.5 and 36.9 °C (92.3 and 98.4
°F), though the skin’s temperature
is lower over protruding parts,
like the nose, and higher over
muscles and active organs.
- Lean and neat. The nails are normally
transparent, smooth and convex,
- Dry foot and
with surrounding cuticles smooth,
brittle nail in
foot intact, and without inflammation.
Normal nails are translucent,
Inspection NORMAL
- Remarkable shiny and firm in texture.
oxygenation Longitudinal bands of pigment can
supply normally be seen in black patients.
With aging nails may lose their
luster, thicken and become yellow.
Nails - Absence of Significant irregularities in color,
lesions and shape, and structure may point to
masses on the underlying problems or previous
- Surface of the trauma or infection. Systemic
skin and dry, changes affect both fingernails
Palpation NORMAL
skin folds, moist. and toenails, but the signs are
typically more prominent in the
- Capillary refill faster-growing fingernails.
less than 3
seconds