Inspect skin

- brown consistent with her genetic background, a 2-cm irregular

shaped birthmark noted on the right dorsal hand, skin is intact
with no reddened areas

Palpate skin
- skin is smooth, moist and warm to touch. it's thin on most
areas however calluses were noted on plantar surfaces. skin is
mobile and returns to original shape quickly. no edema noted.

Inspect scalp and hair

- Hair shoulder length, straight and dyed in brown approximately
4 inches from the hair roots. Scalp is dry and clean. No lesions
and infestations noted.
Palpate scalp and hair
- Hair is smooth, shiny and firm.

Inspect nails
- Nails are clean with pink tones. The angle between the nail
base and the skin is 160 degree.

Palpate nails
- Nails are immobile, smooth and firm.

Capillary Refill Test

- As pressure is released, pink tones return at approximately 1
second.
Inspect head and face
- Head is erect, round, symmetric and midline. it is hard, smooth
and free of lesions. Face is symmetric with diamond-shaped
appearance. No involuntary movements noted.

CN V
-clench teeth: masseter and temporal muscles contract
bilaterally
- sensory: correctly identifies sharp, dull and light sensation on
forehead, cheeks and chin
- corneal reflex: intact; eyelids blink

Inspect and Palpate TMJ

- Now swelling or crepitation with movement. Mouth opens and
closes fully. Lower jaw moves laterally smoothly.
Inspect eyes and surrounding structures
- No lesions, redness, swelling and discharges noed. Lower
eyelid is upright without inward or outward turnings. Eyelashes
are evenly distributed and curve outwardly.
- Eyeballs arre symmetrically aligned i sockets c protruding or
sinking.
- Bulbar conjuctiva is clear and moist. Sclera is white.
- Palpebral conjuctiva is clear and free of swelling, lesions,
foreign bodies and trauma.
- Lacrimal apparatus is free of swelling or redness; no drainage
is noted from puncta nasolacrimal gland is palpated.
- Cornea is transparent with no opacities; smooth and moist.
Lens is free of opacities
- Iris is round, flat and evenly colored brown
- Pupils are round and centered in iris. Equal in size: 3 mm.

Cover test
- The uncovered eye remain fixed straight ahead and covered
eye remain fixed ahead after uncovered.

Cardinal Gaze
- Eye moves smooth and symmetric throughout all six directions.

Color vision
- Correctly identifies number on Ishihara plates

Corneal Light Reflex

- reflected light on the corneas are the same spot on each eye
CN II
- distant: Distant visual acuity is 20/
- near: Near visual acuity is 14/14
- confrontation: able to see the fingers as I see it

CN III, IV, VI
- Margins: eyelids cover about 2 mm of the iris
- Cardinal gaze
- Pupillary response to light and accommodation: pupils
constricted consensually and directly about 2 mm.

Inspect external ears

- Ears are equal in size bilaterally (cm).
- Auricle aligns with the corner of each eye.
 - Earlobes are free
- Ears are smooth, free of lesions, lumps or nodules. Color is
consistent with facial color. No discharge noted.

Inspect internal ears

- Small of amount of soft, moist and odorless cerumen is
present

Palpate auricle, tragus and lobule

- Nontender

Watch Tick Test

- Able to hear the ticking sound on both ears
CN VIII
- Whisper test: able to correctly repeat two-syllable words as
whispered
- Weber: Vibrations are heard equally in both ears. No
lateralization of sound
- Rinne: Air conduction is heard longer than bone conduction

Inspect external nose

- Color is same as the rest of the face, smooth and symmetric.
No tenderness reported by client.

Inspect internal nose

- Nasal mucosa is pink, moist and free of exudate. Nasal
septum is intact, midline and free of ulcers. Turbinates are
dark pink, moist and free of lesions
Nares patency
- Able to sniff through each nostril while other is occluded

Palpate sinuses
- Frontal and maxillary sinuses are nontender
Percuss sinuses
- Nontender
Transilluminate sinuses
- Red glow transilluminates frontal sinuses and on hard palate;
air-filled sinus

CN I
- Correctly identifies scents on each nostril while other is
occluded
Inspect external structures of mouth
- Lips are pinkish, smooth, moist without lesions or swelling
Inspect internal structures of mouth
- 27 pearly whitish teeth with smooth surfaces. Missing right
premolar tooth. No decayed areas. Gums are pink and moist.
No lesions or masses.
- Buccal mucosa is smooth, moist and free of lesions.
- Tongue is pink, moist with papillae present. No lesions are
present. Ventral surface of tongue is smooth, shiny, pink with
visible veins and no lesions
- Hard palate is pale pink with transverse rugae
- Tonsils are visible with 1+ grading; pink and symmetric. No
swelling or lesions noted.
- Uvula is fleshy and hangs freely in the midline
CN VII
- Able to smile, frown, wrinkle forehead, show teeth, puff
out cheeks, purses lips, raises eyebrows and close eyes
with symmetric movements.
- Correctly identifies flavor

CN IX and X
- Say “ah”: uvula and soft palate rise bilaterally and
symmetrically on phonation
- Gag reflex: Gag reflex is intact
- Ability to swallow: swallows w/o difficulty
- Post 1/3 of tongue: able to identify flavors

CN XII
- Tongue movement is symmetric & smooth. Bilateral strength
is apparent.
Inspect neck
- Symmetric, with head centered and w/o bulging masses
- Swallow water: thyroid cartilage, cricoid cartilage move
upward symmetrically as the client swallows

Palpate neck lymph nodes

- Preauricular, post auricular, occipital, tonsillar,
submandibular, submental, superficial cervical, deep
cervical chain, post cervical, supraclavicular
- Nontender and without swelling

Palpate trachea
- Trachea is midline
Palpate thyroid gland
- Thyroid gland is slightly palpable, smooth firm and nontender.
Inspect jugular vein
- At 45 degree and greater inclination, jugular vein is not
distended.

Evaluate jugular venous pressure

-
Auscultate carotid artery
- No bruits are heard
Palpate carotid artery
- Pulses are equally strong, regular with +2 strength
Test Cervical ROM
- Full ROM; able to perform cervical flexion, extension, lateral
bending and rotation against resistance
Inspect breasts
 - Round, one breast is larger than the other, color is lighter
than upper extremities. Smooth without striae, lesions, scars
and edema.
- Nipples are everted and equal bilaterally in same location on
each breast.
- No discharge
- Areolas are pink and round.
- Breasts rise symmetrically with no sign of dimpling or
retraction. Hang freely and symmetrically.
Palpate breasts
- Warm, same as the rest of the body. Smooth and firm. No
masses palpated
- Nipples erected and aerolas pucker in response to stimulation
Palpate lymph nodes
- Brachial, midaxillary, suprascapular, pectoral,
supraclavicular, infraclavicular nontender and no swelling.
Inspect posterior thorax
- Scapulae are symmetric and nonprotruding. Shoulder and
scapulae are at equal horizontal positions. Anteroposterior to
transverse diameter is 1:2 ratio
- Do not use accessory muscles in breathing
Inspect anterior thorax
- Sternum is midline and straight. Retractions are not
observed. Ribs slope downward with symmetric intercostal
spaces.
- Respirations are relaxed, effortless and quiet. Regular rhythm
and normal depth.
Palpate post/ant thorax
- no tenderness or pain reported. Temperature is equal
bilaterally. No palpable crepitus and masses. Fremitus is
symmetric are identifiable in the upper regions of the lungs.
Percuss post/ant thorax
- Post: resonance over lung tissue and flat tones over scapula
- Ant: resonance over lung tissue; dullness over breast;
tympany over stomach and flatness on bones
Chest expansion
- Thumbs move outward in s symmetric fashion
Diaphragmatic excursion
- 3-5 cm
Auscultate breath sounds (post/ant thorax)
- Deep breath to the mouth
- Bronchial sounds noted in trachea and thorax.
Bronchovesicular sounds between scapulae (post); upper
sternum (ant). Vesicular sounds noted in the peripheral lung
fields.’
Auscultate advertious sounds (post/ant thorax)
- No adventitious sounds noted
Auscultate voice sounds (post/ant thorax)
- Bronchophoy: voice is soft, muffled and indistinct
- Egophony: soft and muffled, “E” is distinguishable
- Whispered pectoriloquy: very faint and muffled
CN XI
- Symmetric and strong contraction of trapezius muscles and
sternocleidomastoid muscle
Inspect spine
- Cervical and lumbar spines are concave and thoracic spine is
convex. Spine is straight from behind
Test Thoracic and Lumbar ROM
- Full ROM, smooth movements
Inspect precordium
- Apical impulse noted on the fifth intercostal space
Auscultate apical pulse
- Regular, 60-100 bpm
Palpate apical impulse
- 1 cm, +1 strength
- No abnormal pulsations
Auscultate S1 and S2
- S1 loudest at the apex of the heart; S2 loudest at the base
Auscultate extra heart sounds & murmurs
- Use bell: no extra heart sounds and murmurs
Inspect upper extremities
Palpate upper extremities
Allen's test
- Radial and ulnar arteries are patent; Pink coloration returns to
the palm about 3 seconds
-
Test ROM Shoulders and Arms
Test ROM Hands and Fingers
Test ROM Wrists

Phalen's test
- No tingling, numbness or pain
Tinel's test
- No tingling or shocking sensation
Test ROM Elbow
Inspect lower extremities
Leg length
- Legs are equal bilaterally
-
Palpate lower extremities
Observe gait
- Able to stand on heels and toes. Toes point straight ahead.
Posture erect, movements coordinated and rhythmic, arms
swing in opposition, stride length appropriate.
Test ROM Hips
Test ROM Knees
Test ROM Feet and Ankles

Homan's test
- Deep vein thrombosis. No pain noted on calf
Lasegue's test
- Nerve root irritation on the lumbosacral area. No pain on the
thigh
Bulge Knee test
- Small amnts of fluid in the knee. No fluid appears in medial
side of the knee.
Ballotement Knee test
- Large amnts of fluid in the knee. No movement of the patella
is noted. Patella rests firmly over the femur.
McMurray's test
- Torn meniscus of the knee. No pain or clicking noted.
Assess peripheral pulses
Inspect abdomen
- Lighter color, no striae, scars, lesions and rashes.
- Abdomen is flat and symmetric
- Slight pulsation of the abdominal aorta; peristaltic waves are
not seen
- Umbilicus is inverted and midline
Abdominal girth
Palpate abdomen
- No masses, swelling and bulges
Palpate liver
- Not palpable (if so: firm, smooth and even)
Palpate spleen
- Palpable, soft and nontender
Palpate kidneys
 - Usually not palpable (if so: firm, smooth and rounded)
Palpate abdominal aorta
- Not palpable and nontender
Palpate urinary bladder
Percuss abdomen
- Generalized tympany; dullness over liver and colon
Percuss liver span
- MCL: 6-12 cm
- MSL: 4-8 cm
Percuss spleen
- 7 cm wide
Percuss kidneys
- No tenderness or pain
Auscultate bowels sounds
 - 5-30 per minute
Auscultate vascular sounds
- Bruits are not heard
Auscultate venous hums
- Not heard
Auscultate friction rubs
- No friction rubs on liver or spleen
Shifting dullness
- Borders between tympany and dullness remain relatively
constant throughout position changes
Fluid wave test
- No fluid wave is transmitted
Rebound tenderness
- No rebound tenderness noted (+ pain as pressure release)
Psoas sign
- No RLQ pain
Obturator sign
- No RLQ pain
Level of Consciousness
- Alert, awake with eyes open. Oriented to what’s happening
and responds and interacts appropriately.
Mood and Affect
- Cooperative and purposeful in her interactions. Calm and
affect is appropriate to the situation.
Dress, hygiene and grooming
- Dress is appropriate for the weather and appropriate on the
developmental level. Clean and groomed appropriately
Facial expressions
 - Maintains eye contact and smiles appropriately
Speech
- Moderate tone, clear with moderate space
Vocabulary
Thought processes
- Expresses full, free flowing thoughts with realistic
perceptions. Healthy and positive thoughts
Attention
- Listens and can follow directions
Orientation
- Oriented to time, place and self
Memory
- Recalls memory without difficulty
Fund of Information
 - Able to answer correctly
Abstract Reasoning
- Proverb. Able to explain and expressed understanding
Similarities
- Able to explain similarities between obejcts
Judgement
- Answers to questions are based on sound rationale
Visual Perceptual and Constructional Ability
- Draws the clock fairly well and can copy simple figures
Rapid Alternating Movements
- Rapidly turns palms up and down
Finger-thumb test
- Touches each finger to the thumb rapidly
Finger-nose test
 - Touches finger to nose with smooth accurate movement with
little hesitation
Heel-to-shin test
- able to run each heel smoothly down each shin
Romberg test
- Stands erect with minimal swaying
Tandem walk
- Maintains balance with tandem walking and with no difficulty
Light sensation
- Correctly identifies light touch
Sharp/Dull sensation
- Correctly differentiates dull and sharp sensatins
Temperature sensation
- Correctly differentiates hot and cold temperatures
Vibratory sensation
- Correctly identifies vibratory sensation
Two-point discrimination
Stereognosis
- Correctly identifies objects
Graphesthesia
- Correctly identifies number written
Kinesthesia
-
Deep Tendon Reflexes
Biceps: elbows flex and biceps contract
Triceps: elbow extends and triceps contracts
Brachioradialis: forearm flexes supinates
Patellar: knee extends, quadriceps contract
 Achilles: plantarflexion of the foot

Superficial Reflexes
Abdominal: abdominal muscles contract
Plantar: flexion of toes

Pathologic Reflexes
Brudzinski’s sign: hips and knees are relaxed and
motionless
Kernig’s sign: no pain is felt and resistance.
CN I = OLFACTORY
CN 2= OPTIC (far, near, peripheral)
CN 3, 4, 6= OCULOMOTOR, TROCHLEAR &ABDUCENS
(margins of eye, cardinal gaze, pupillary reaction)
CN 5= TRIGEMINAL (clench teeth, light & pain head)
CN 7= FACIAL (facial expres. & ant. 2/3 tongue)
CN 8= (VESTIBULOCOCHLEAR (whisper, weber &rinne)
CN 9 & 10= GLOSSOPHARYNGEAL & VAGUS (uvula,gag,
ability to swallow, post. 1/3 tongue)
CN 11= SPINAL ACCESSORY (shrug &head rotation)
CN 12= HYPOGLOSSAL (stick out tongue & move side2side)
Biceps = C5 & C6 Patellar= L2, L3, L5
Brachioradialis- C5&C6 Achilles= S1, S2
Triceps= C6, C7, C8 Abdomen= T8-T12