D.

PHYSICAL ASSESSMENT
Name: Mrs. M
1. SKIN
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color Inspection Inspect variations in skin Color varies from light Mrs. M has an even There are no signs of
color under natural sunlight to to ruddy pink or dark brown skin color. abnormalities.
ensure accuracy findings. brown, depending on the
race. Color is uniform
except for sun exposed
areas or normally
lighted pigmented areas
(nailbeds, palms, lips) in
dark skinned people.
Lesions Inspection Note for color, size, and Freckles, skin tags in Mrs. M has a stretch Striae are present due to
anatomic location and elderly, and some types mark or striae on the several births.
distribution. of birthmarks and moles bottom area of her
are normal. belly.

Palpation
Palpate lesions with finger
pads for mobility and contour
(flat, raised, or depressed) and
consistency (soft or durable)
Moisture Inspection Note amount and distribution
and Palpation
Moles are present in
the patient neck and
chest.
Moisture varies with Soft skin, however The patient skin is dry
activity, body and there are areas that are due to insufficient fluid
environmental dry. intake.
 temperature, and
humidity in skin folds
and the axillae.
Temperature Palpation Palpate with dorsum of hand Temperature should be 36.9 °C is the The patient temperature
noting for uniformity of uniform and within temperature of the is warm to touch.
warmth. normal range. client skin.
Texture (quality, Palpation Palpate with finger pads in Texture is not uniform The palms are soft, and There are no signs of
thickness, different areas like the palms and soles the soles are not thick. abnormalities.
suppleness) are thicker than any Wrinkles are also
areas. Wrinkled and present due to aging,
leathery skin in the but other than that,
elderly results from the there are no lesions.
normal aging. Process
with decreased collagen,
subcutaneous fats, and
sweat glands.

AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND

TO ASSESS INTERPRETATION

Mobility and turgor Palpation Assess mobility and turgor to
(elasticity) measure elasticity of skin to
determine the degree of
hydration.
Palpate dependent areas like
the sacrum, feet, and ankles
Absence of indention is After pinching the There are no signs of
dependent areas and the client's skin, it quickly abnormalities.
resilience of the skin turns back to its
spring back to its original position after
previous state after 0.3 secs.
being pinched.
There are no signs of
edema.
 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
(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/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
 Color and Inspect Assess for color and Color varies from black The patient’s hair is Chemically colored hair.
Distribution distribution of scalp hair, to pale blonde based on evenly distributed, and
eyebrows, eyelashes, and the amount of melanin her hair is chemically
body surface. present. color black.
Texture and oiliness Palpation Assess for the skin’s texture Thin, straight, coarse, The patient’s hair is Excessive application of
and oiliness with the use of thick, or curly. Hair is thin, frizzy, and dry. chemical hair color lead
palm. shiny and resilient to dryness in the hair.
infestation Inspection Assess for any presence of Free from any There is no presence of There are no signs of
infestation by examining the infestation. any infestation. abnormalities.
hair and scalp.

3. SCALP
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Scaliness and scars Inspection Part the hair repeatedly all The scalp should be The scalp is clean and There are no signs of
over the scalp and inspect for shiny and smooth smooth, there is no abnormalities.
scaliness and scars. without lesions, lumps, signs of any lesions or
or masses. masses.
Tenderness, lesions, Palpation Place finger pads on the scalp Absence of redness or There is no tenderness, There are no signs of
lumps, masses at the front and palpate down scaliness. lesions, lumps, or abnormalities.
the midline and each side for masses on the patient’s
tenderness, lesions, lumps, or scalp.
masses.
 4. NAILS
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color, shape, and Inspection Inspect for color and shape Nailbeds is highly The patients nail bed is There are no signs of
texture vascular with a pink pink and the shape of abnormalities.
color in light skinned the nail is round.
clients and longitudinal
streaks of brown or
black pigmentation in
dark skinned clients.
Angle between
fingernail and base is
about 160 degrees.
Upon palpation, the
Palpation Palpate nailbed for firmness patient’s nails are
and texture Nailbed is firm smooth and firm.

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.
When pressure is Upon the release of There are no signs of
released from the nail, it pressure from the nail, abnormalities.
promptly returns to its it quickly returns to its
normal color. usual color in less than
1 second.
Tissue surrounding the The tissue surrounding There are no signs of
nail is intact. the nail remains intact abnormalities.
and free from any
 lesions.

5. SKULL
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Shape and symmetry Inspection Inspect skull for shape, Rounded, symmetrical, The patient’s skull is Upon examining the
symmetry, size in proportion normocephalic, and round and symmetrical. patient's skull reveals a
to body and position. upright. well-proportioned and
symmetrical structure.

Contour, Masses, Palpation Palpate with fingerpads Smooth, non-tender, free The patient’s skull is There are no signs of
Depressions and beginning in frontal area and of masses or smooth and free from abnormalities.
Tenderness continuing over parietal, depressions. any signs of masses,
temporal, and occipital areas depressions or
for contour, masses, tenderness.
depressions, and tenderness.

6. FACE
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Facial features Inspection Inspect facial features for May be oval, round, or The patient's face is There are no signs of
expression, shape, and square. Symmetrical round and symmetrical abnormalities.
symmetry of eyebrows, features and movement. in shape, with
 placement of nose, eyes, and
ears.
Edema and masses Inspection Inspect for any presence of
edema and masses
symmetrical features
such as eyebrows, nose,
eyes, and ears.
No edema and masses There is no presence of There are no signs of
edema or masses on the abnormalities.
patient’s face.

7. EYES
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION

Visual Acuity Inspection Test visual acuity. Normal vision based on The patient's visual The patient indicate that
the Snellen chart is 20/20 acuity at a distance of she wears glasses for
1. Position Snellen chart 20
at the distance of 20 feet 10 feet is recorded as eye protection.
ft. in front of client.
2. Remove corrective the normal eye can read 20/20.
lenses, if appropriate. the chart).
3. Instruct client to cover
one eye and read lines
starting with top of chart
from left to right.
4. Note the line where client
reads more than half of
the letters.
5. Record results as a
fraction sc (without
correction), 20/ distance
number, and the number
of the letters missed.
 6. Repeat same steps for the
other eye.
7. If appropriate, repeat
steps with patient
wearing the corrective
device.
Inspection Test eye for extraocular Eye movement should The smooth eye There are no signs of
muscle movements: be symmetrical as both movement of the abnormalities.
eyes follow the direction patient is evident, with
1. Place the client in sitting
of the gaze and both eyes smoothly
position.
2. Instruct the client to hold converge on the held tracking the gaze
head still. object as its moves direction and
3. Ask the client to follow toward the nose. converging on the
an object with eyes. object as it moves
4. Move objects with 6 closer to the nose.
fields of gaze.
***The 6 Fields of Gaze The upper eyelids cover The upper eyelids of Upon examination, the
only the uppermost part the patient exhibit no upper eyelids of the
1. Conjugate left lateral
of the iris and are free signs of nystagmus, patient remain stable
gaze
2. Left down and lateral from nystagmus indicating a lack of and without any
gaze (involuntary rhythmical involuntary and abnormal twitching or
3. Right down and lateral oscillation of the eyes). rhythmic movements in oscillations.
gaze A few beats of the eyes.
4. Conjugate right lateral nystagmus with extreme
gaze lateral gaze can be
5. Right up and lateral gaze normal.
6. Left up and lateral
5. Observe for parallel eye
movement.
6. Pause during upward and
lateral gaze field to detect
 in voluntary rhythmic
oscillation of eyes.
7. Note position of upper
eyelid in relation to the
iris and eyelid bag 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.

AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND

TO ASSESS
External anatomical Inspection Observe upper eyelid.
structures
Check eyes and eyelids for
inflammation, crusting, edema Eyes and eyelids should
or masses.
Inspect lacrimal glands and
sacs for swelling.
INTERPRETATION
Upper eyelid should The patient’s upper There are no signs of
overlap iris. eyelid margin overlaps abnormalities.
the iris.
be free from There is no presence of
inflammation, crusting, inflammation, edema,
edema or masses. or masses on the
patient’s eye and
eyelids.
The patient’s lacrimal
glands indicate no
redness or swelling.
Palpation Check for blocking of Lacrimal gland should The patient’s lacrimal There are no signs of
nasolacrimal duct by pressing not be palpable. gland is not palpated, abnormalities.
against inner orbital rim of and the tears flow
lacrimal sac. easily from the lacrimal
Tears flow freely from gland to the lacrimal
Inspect duct by palpating on
the lacrimal gland over duct through the cornea
the lacrimal sac and observing
the cornea and and conjunctiva.
for regurgitation of fluid.
conjunctiva to the
lacrimal duct.
Inspection Inspect bulbar and palpebral Bulbar is transparent The bulbar of the There are no signs of
conjuctiva and sclera. with small blood patient is clear and abnormalities.
vessels. characterized by the
a. Instruct client to look
presence of small blood
upward while depressing Palpebral conjunctiva
lower lid with thumb. vessels.
covering the inside of
b. Inspect for color, redness, the upper and lower The palpebral
swelling, exudates, or eyelids is pink and conjunctiva of the
foreign bodies. moist. patient is clear, moist
c. Inspect cornea, lenses,
and free from any
pupil, iris, and anterior Sclera is white with
swelling.
chamber: some superficial blood
1. Stand in front of vessels depending on the Sclera is white, and the
the client. race. cornea of the patient is
2. Shine penlight transparent, moist and
directly on cornea.
clear.
3. Move light
laterally and view Corneas are moist, shiny
cornea from that and clear.
angle; note color, Lenses are transparent.
discharge, and
lesions. Pupils are black, round
 4. Look at pupil and
note size and
shape.
5. Shine penlight
directly on pupils
to assess lens and
color.
6. Look at iris for
size, and ability of
pupils to react to
light.
7. Shine a light
obliquely through
anterior chamber
from lateral side
toward nasal side.
Inspection Test for papillary response to
light and reaction to
accommodation in dimly lit
room.
1. Instruct client to look
straight ahead.
2. Bring penlight from side
of the client’s face to
directly in front of the
pupil.
3. Note quickness or
response to light.
4. Shine light into same eye
observing for response or
pupil for equality of size
and equal diameter,
ranging from 2-6mm.
Entire iris should
illuminate when shining
light laterally too
nasally.
Pupils should constrict The patient's pupils The patient's pupils
quickly in direct rapidly contract in exhibit a prompt and
response to light and the direct reaction to light, simultaneous
opposite pupil should and the corresponding constriction in response
also constrict. pupil on the opposite to direct exposure to
side also constrict. light. This coordinated
Pupil should be equal in
reaction indicates a
size. The size of the patient's
healthy and
pupil is equal.
Papillary synchronized pupillary
accommodation causes response, indicative of
constriction in response normal neurological
to objects that are near. function and visual
pathways.
Pupillary dilatation
occurs when pupils
 and repeat steps to the accommodate objects at
other eye. a distance, with
5. Instruct client to gaze at symmetrical
your finger held 4-6 convergence of eyes.
inches from her nose then
to glance at a 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/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
External ear Inspection Examine external ear, called Symmetrical, with upper The patient's ears are Upon inspection the
the auricle or pinna for attachment at eye corner equal size, the auricle patient's ears
placement, symmetry, color, level, and is fleshed aligns with the corner demonstrate
discharge and swelling. colored. of the eye, and the symmetrical
color of her ears proportions, with the
matches her skin tone. auricle aligning
appropriately with the
corner of the eye with
no signs of any
 abnormalities.
Palpation Palpate the auricle between Firm, smooth, free from The auricle and pinna There are no signs of
the thumb and index finger lesions and pain. of the patient is abnormalities.
noting lesions or tenderness smooth, firm and free
by moving auricle up and from any lesions or
down, same with the mastoid swelling.
tip.
Press inward on tragus noting
any tenderness.
Auditory acuity Inspection The Whispered Voice Test The client should be The patient’s hearing is There are no signs of
able to repeat whispered excellent and can abnormalities.
1. Instruct the client to
words. repeat whispered
occlude one ear with
finger and repeat the words.
words when heard.
2. Stand 1-2 feet away
from the client, out of
view to avoid client
from lip reading, and
softly whisper
numbers on side of the
ears. Increase voice
volume until client
identifies uttered
number.
3. Repeat procedure on
other ear.
4. Record results.
 9. NOSE AND SINUSES
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
Nose Inspection Inspect the nose for
symmetry, deformity, flaring,
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.
Nasal cavities Inspection Inspect the nasal cavity with a
penlight:
a. Tilt client’s head in an
extended position.
b. Place non dominant
hand on client’s head
using your thumb, and
lift the tip of the nose.
c. With the lit penlight,
asses each nostril; and
note for color of
anterior nares, nasal
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Located symmetrically, The patient’s nose is The patient's nose is
midline of the face, and symmetrical, located in symmetrical alignment,
is without swelling, the midline of the face, positioned centrally on
bleeding, lesions, or and free from any the face. Furthermore, it
masses. lesions, swelling, or is observed to be free
bleeding. from any lesions,
swelling, or signs of
The patient’s nostril is
Each nostril is patent. bleeding. This indicates
patent.
a normal and healthy
nasal condition.
Mucosa is pink or dull The patient’s septum is There are no signs of
without swelling or in the midline and abnormalities.
polyps. intact, mucosa is pink
and there are no signs
Septum is midline and
of any bleeding or
intact.
swelling.
A small amount of clear
watery discharge is
normal.
 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.
10. Mouth
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
Breath Inspection Stand 12-18 inches in front of
client and smell the breath.
Observe lips for color,
Lips
moisture, swelling, lesions
a. Instruct client to open
mouth and use tongue
depressor to retract
buccal mucosa and
note color, hydration,
None-tender air-filled Upon palpation, the There are no signs of
cavities. nasal sinuses are free abnormalities.
from sensitivity or
discomfort when
touched or palpated.
Resonant sound upon There is resonant sound
percussion. upon percussion.
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Breath should smell The patient's breath has Due to poor oral
fresh. a slight odor. hygiene.
The patient's lips are The lips appear dry,
brown in color, dry, and which may suggest a
free from any lesion. lack of moisture and
there are no visible
lesions or abnormalities
present.
Lips and mucosa should
be pink, firm, and moist
without inflammation or
 inflammation, or lesions.
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 Gums are pink, smooth The patient's gums are There are no signs of
and note color, edema, and moist. pink, moist and firm. abnormalities.
retraction, bleeding and
lesions.

Palpation Palpate gums with tongue

blade for texture
Ask client to clench teeth to
assess position and alignment
Teeth Inspection
with the use of a tongue
depressor, expose molars and
note for tartar, cavities,
extraction and color.
Inspection Instruct client to protrude
tongue:
1. Inspect dorsum of
tongue and note for
color, hydration,
texture, symmetry.
Gums are firm.
Teeth are properly The patient's teeth are Upon inspection it
aligned, smooth, white not properly aligned, indicates dental
and shiny. with a slightly irregularities, poor oral
yellowish color, and hygiene, and variations
there are spaces in tooth development.
between each tooth.
When protruded, tongue The patient's tongue is The dorsal surface of the
lays midline, medium in midline, with the tongue appears smooth
red or pink in color, dorsal surface smooth and devoid of any
and free of lesion.
moist and smooth along lesions or abnormalities.
lateral margins, with
free mobility. The patient's tongue
color is pink and is
 Tongue 2. With penlight, inspect
sides and ventral
surface and note for
size, texture, nodules,
or ulcerations.
3. Still with penlight,
inspect floor of mouth,
salivary glands, and
Palpation duct openings.
Grasp tongue with a gauze
and gently pull it to one side
and palpate full length of
tongue.
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
Palate Inspection Inspect the soft and hard
palate with a penlight:
a. Instruct client to
extend head backward
and hold mouth open.
b. Inspect the hard palate
(roof of mouth) and
soft palate for color,
shape, lesions.
Inspection Inspect pharynx using tongue
depressor and penlight:
a. Explain procedure to
The dorsal surface is
slightly rough (taste smooth and moist in
buds) and free from texture.
lesions.
The ventral surface is
highly vascular, smooth,
moist, and free of
lesions.
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Palates are concave and The patient's palates are There are no signs of
pink. concave and the soft abnormalities.
palate is smooth with a
Hard palate has ridges.
light pink coloration.
Soft Palate is smooth.
The patient's hard
palate has ridges and is
firm in texture.
With phonation, the soft The patient's pharynx Upon inspection it is
palate and uvula rise and tonsil are pink in noted that the patient's
symmetrically. color and free from any pharynx and tonsils
exhibit a normal and
 Pharynx client. The pharynx is pink, lesions. healthy appearance. The
b. Instruct client to tilt vascular, lesion free. coloration is described
head back and open as pink, which is
mouth. Tonsil size is evaluated
indicative of the typical
c. With non-dominant using the grading scale.
hue of these structures.
hand, place tongue
depressor on middle
third of tongue. With
the dominant hand,
shine light into back of
throat.
d. Instruct client to say
“ah” and note position,
size, appearance of
tonsils and uvula.
e. Inform client of
eliciting gag reflex by
touching the posterior
1/3 of tongue with
tongue blade if palate
and uvula fail to rise
symmetrically with
phonation.

11. NECK
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Inspection Instruct client to: Muscles are The patient's muscles We observed that the
symmetrical with head exhibit symmetry, and patient's neck
Symmetry and a. Flex chin to chest and
the head is centrally demonstrates
Musculature to teach side and in central position. positioned. unrestricted movement,
shoulder to test and there are no
anterior Movement though full The patient's neck
reported complaints of
sternocleidomastiod range of motion without movement can move
discomfort.
muscle. complaint of discomfort freely without any
b. Hyperextend the neck or limitation. complaints of
backward to test discomfort.
posterior trapezia.

Palpation Palpate lymph nodes and Lymph nodes should not The patient’s lymph There are no signs of
instruct client to relax and be palpable. Small, nodes are not palpable. abnormalities.
flex neck slightly forward. movable nodes are
insignificant.
1. Stand in front of
seated client.
2. Methodically palpate
Lymph nodes 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. Midline position above The patient’s trachea is We observed that the
the suprasternal notch. located in a midline patient's trachea is
position above the appropriately situated in
suprasternal notch. And the midline position
 Palpation Place thumbs and index finger there is no pain upon above the suprasternal
on sides of trachea and apply palpation. notch. And there is no
gentle pressure and palpate. reported pain upon
palpation, indicating that
the trachea is not tender
or sensitive to touch.
Palpation With client seated, assessment Thyroid cannot be The patient's thyroid is There are no signs of
may be done with posterior visualized. non tender and has a abnormalities.
and anterior approach: soft texture when
touched.
A. POSTERIOR
APPROACH It may or may not be
Thyroid
1. Stand behind client felt.
and place thumbs No bruits on
on nape of neck and auscultation.
bring fingers If felt, it should be
interiorly around smooth, soft, non-tender
neck with their tips and not enlarged.
resting over tracheal
rings.
2. Ask client to tilt
chin forward to
relax neck muscles
and swallow.
3. Palpate the isthmus
rise under fingers
and feel each lateral
lobe before and
while client
Auscultation 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
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.
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/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Inspection Place client in sitting position Respirations are quite, The respiration rate is We observed that the
with arms folded across chest, effortless, and regular, 18 breaths per minute. respiration rate of 18
back exposed. with 12-20 breaths per The thorax moves breaths per minute
minute. smoothly and quietly indicates a normal and
1. Assess shape and
during inhalation and steady breathing pattern.
symmetry by taking note Thorax rises and falls in
of the rate and rhythm of exhalation. No The smooth and quiet
unison with respiratory
deformities are movement of the thorax
Shape, symmetry, respirations, movement of
and diameter chest wall with deep
inspiration and full
expiration.
2. Estimate anteroposterior
diameter in proportion to
lateral diameter.
Lesions Palpation 1. Palpate for lesions or
areas of pain.
2. Palpate thoracic
expansion at 10th rib by
placing thumb close to
client’s spine and spread
hands over thorax. Note
divergence of thumbs;
feel for range and
symmetry of movement
during deep inhalation
and full exhalation.
3. Place ulnar aspect of open
hand at right apex of lung
and place hand at each
posterior thorax location.
Then instruct client to say
“99” and palpate for
tactile fremitus
(vibrations caused by
vibrations). Note areas of
increased and decreased
cycle. detected upon during both inhalation
palpation. and exhalation indicates
Ribs slope across and
proper respiratory
down, without
function. The absence of
movement or bulging in
any deformities upon
the intercostals spaces.
palpation indicates a
structurally sound chest
without noticeable
irregularities.
Thumb should separate Upon palpation, there The findings indicates
an equal distance of 3- are no lesions or that there are no
5cm and in the same tenderness detected on noticeable
direction during thoracic the posterior thorax. abnormalities, skin
expansion and meet in irregularities, or areas of
The symmetry of
the midline on discomfort on the back
movement is evident
expiration. of the thoracic region.
while palpating the
thoracis expansion.
Posterior thorax is free Fremitus is symmetric We observed that the
from tenderness, lesions and easily identified in symmetry of movement
and pulsations. the upper region of the during palpation of the
lungs. It is equal on thoracic expansion
both sides of the indicates a balanced and
Fremitus is equal on thorax. uniform expansion of
both sides of thorax, the chest.
strongest at the level of
We also observed that
tracheal bifurcation.
the fremitus, are evenly
distributed and readily
noticeable in the upper
 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
moving hands from side
to side across the top of
Sound Percussion each shoulder. Note sound
produced from each
percussion strike and
compare with
contralateral sound.
2. Continue downward and
post lateral every other
intercostals space. Note
intensity, pitch, duration,
and quality of percussion.
Breath sounds Auscultation 1. Place diaphragm of
stethoscope on right lung
apex. Instruct client to
inhale and exhale deeply
and slowly when
stethoscope is felt on the
back. Repeat on left lung
apex.
2. More downward every
portion of the lungs. The
symmetry in fremitus
implies a balanced and
uniform transmission of
vibrations during
palpation, particularly in
the upper respiratory
regions.
Air filled lungs create a Upon percussion, The presence of
resonant sound. resonant sound is resonant sounds during
heard. percussion on the thorax
and lung assessment is a
positive indication.
Resonance is a normal
and expected sound,
Identify contralateral suggesting that the
sound; bones create flat underlying lung tissue is
sound. Thorax is more air-filled and healthy.
resonant in children and
thin adults.
Posterior sound: No adventitious Upon auscultation, there
vesicular and sounds, such as is no abnormal sounds,
bronchovesicular. crackles or wheezes are such as crackles or
auscultated. wheezes, were detected.
Lateral sound: vesicular
 other intercostals spaces A large chest will
and auscultate, placing produce decreased
stethoscope in the same breath sound.
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/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Inspection Place client in sitting position Thorax rises and falls in The respiration rate is We observed that the
or supine position. Inspect unison with respiratory 18 breaths per minute. respiration rate of 18
client’s chest for: cycle, ribs at 45 degrees The thorax moves breaths per minute
Symmetry, rhythm angle with sternum. smoothly and quietly indicates a normal and
1. Symmetry and depth
and slope Inspiratory breath during inhalation and steady breathing
of movement.
2. Slope of ribs and sounds are not audible at exhalation. pattern. The smooth
musculoskeletal a distance of more than and quiet movement of
deformities. 2to 3 cm from mouth. the anterior thorax
during both inhalation
 and exhalation
indicates proper
respiratory function.
Tenderness, Palpation 1. Place fingerpads on Same normal findings There is no presence of The findings indicates
pulsation, masses right apex above the with posterior palpation. tenderness or pain that there are no
and crepitance clavicle. Proceed palpated over the area. noticeable
downward to each rib abnormalities, skin
and intercostals space irregularities, or areas
and note for of discomfort on the
tenderness, pulsation,
back of the thoracic
masses and crepitance.
region.
Repeat on left side.
Respiratory 2. Assess respiratory
excursion excursion by placing
Fremitus is symmetric Fremitus is symmetric
thumbs along each
and easily identified. It and easily identified
costal margin with
hands on lateral rib is equal on both sides. which is normal.
cage. Instruct client to
inhale deeply; note for
divergence of thumbs
on expansion; feel
range and symmetry
of respiratory
Tactile Fremitus movement.
3. Palpate for tactile
fremitus. Gently
displace female
breasts as necessary.
Percussion Percuss anterior surface by: Resonant sound over Percussion elicits Upon percussion and
lung tissue dullness over breast auscultation, the
1. Percuss 2-3 strikes
(hyperresonance in tissue, the heart, and the symmetry and sound
along right lung apex
 and repeat on left lung children and thin adults) liver. are found normal.
apex. Proceed
downward, percussing Cardiac, liver, and
in every ICS going gastric silhouettes emit
from right to left in dull sound.
same positions on both
Ribs emit flat sound.
sides.

Symmetry and Assess each thorax area:

sound
1. Resonant lung filled.
2. Cardiac dullness: 3rd-
5th ICS left of sternum.
3. Liver dullness: place
finger parallel to upper
border of expected
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
Auscultation
through the mouth and
compares symmetrical areas
of lungs from above
downward:
Tympany is detected There are no signs of
Anterior sounds:
over the stomach, and abnormalities.
bronchial,
flatness is detected over
bronchovesicular,
the bony prominence.
vesicular.
 1. Listen to breath A large chest will
sounds and note produce decreased
intensity and identify breath sounds.
variations from
normal.
2. Identify any added
sounds by location on
chest wall and time in
the respiratory cycle.
3. If breath sounds are
diminished, ask client
to breath hard and fast
with mouth open.

13. CARDIOVASCULAR
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Arterial Pulses Palpation Compress the radial artery Normal Heart rate Upon palpation, the Pulse rate of 96bpm
with your index finger and patient’s pulse rate is 96 falls within a moderate
middle finger. beats per minute. range and is generally
considered within the
normal adult heart rate
range.
Heart Inspection Precordial Movement When the patient was Upon inspection, the There are no signs of
1. Position the patient supine auscultated, the chest appears abnormalities.
with the head slightly elevated pulsation in the mitral symmetrical without
2. Always examine from the area can be palpable and visible abnormalities or
Palpation patient's right side. when no signs of deformities.
3. Palpate for point of irregular rhythm and
maximal impulse. (Normally murmur sounds.
 located at 4th or fifth ics, Upon palpation, the
1mcl) pulse is regular and
4. Listen with diaphragm at strong, and the point of
Auscultation the right 2nd ICS maximal impulse is
5. Listen to the 2nd ICS near palpable at the apex,
the sternum. usually at the fifth
6. 3rd, 4th, 5th ICS near
intercostal space in the
sternum
midclavicular line.
7. Listen for apex

Upon auscultation, heart

sounds are clear and
well-defined.

Tissue perfusion Palpation Perform the Allen Test to Palms should turn pink The palm and fingers There are no signs of
determine patency of radial promptly. quickly regain their abnormalities.
and ulnar arteries. Instruct normal color, indicating
client to rest hands on lap. good blood flow through
1. Compress both the radial the released artery.
and ulnar arteries.
2. Firmly compress arteries
and instruct clients to open
their hands.
3. Note the color of the palms.
4. Release one artery and note
the color of the palm.
5. Repeat steps on other
arteries on the same hand.

14. ABDOMEN
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Generalized Inspection Placing client in supine Contour is flat or The patient’s abdomen The patient's abdomen
appearance of position with knees flexed rounded and bilaterally is evenly round and is evenly round
abdomen over a pillow, hands at side or symmetrical. there are striae detected indicated a normal
over the chest, undrape due to several births. distribution of
patient from xiphoid process abdominal content
to symphysis pubis to expose Umbilicus is depressed without significant
abdomen. and beneath the The patient’s umbilicus asymmetry or bulging.
abdominal surface. is in the midline, and the The presence of striae,
1. Inspect abdomen
from rib margin to skin color is same to the often associated with
pubic bone and note surrounding abdominal multiple childbirths,
for contour and Visible peristalsis is skin tone. indicates the stretching
symmetry. slowly transverses the of the skin over time.
2. Inspect umbilicus abdomen in slanting
for contour, location, downward movements The patient’s abdomen
signs of as observed in thin is smooth and it is even There are no signs of
inflammation or client. Pulsations of the respiratory movements. abnormalities on the
hernia. abdominal aorta are abdomen of the client.
3. Observe for smooth, visible in the epigastric
even respiratory
area in thin clients.
movements.
No abnormal
4. Observe for surface
motions (visible respiratory movements
peristalsis) are observed.
Bowel sounds Auscultation Auscultate the bowel sounds High pitched sounds Bowel sounds are The presence of audible
on the abdominal quadrants heard every 5 to 15 audible in various bowel sounds in
using the diaphragm of the seconds as intermittent abdominal quadrants, as various abdominal
stethoscope. gurgling sounds in all 4 they represent the quadrants indicates
quadrants as a result of movement of contents normal gastrointestinal
 1. Begin by placing the fluid and air movement through the stomach. motility.
diaphragm on the in GIT.
RLQ. Listen for a
full minute to the
frequency and
character of bowel
movements.
2. Repeat same step
proceeding in Bowel sounds should
sequence to RUQ, always be heard at the
LUQ, and LLQ. ileocecal valve.
3. Listen at least for 5
minutes before
concluding the
absence of bowel
sounds.
Abdominal Percussion Begin percussion in RLQ, Tympany is heard Tympanic sounds are Tympanic sounds over
quadrants move upward to RUQ, cross because of air in the over air-filled structures air-filled structures
over to LUQ, and down to stomach and intestines. like the stomach and such as the stomach
LLQ. Note when tympani Dullness is heard over intestines and a hollow, and intestines indicate
changes to dullness. organs. drum-like sound is normal findings during
produced upon abdominal percussion.
percussion.

15. NEUROLOGIC SYSTEM

ASSESSMENT OF COMMON DEEP TENDON REFLEX
TYPE ASSESSMENT NORMAL REFLEX KEY FINDINGS ANALYSIS AND
 INTERPRETATION
1. Flex client’s arm No difficulties detected. The bicep reflex is
between 45 degree normal.
Biceps angle and 90 degree. There should be flexion of arm
2. Place thumb firmly on at elbow.
biceps tendon just
above the crease of
antecubital fossa.
3. Tap thumb with reflex
hammer.
Triceps 1. Flex client’s arm at 45 Extension of elbow When the triceps tendon is The contraction of the
degree and 90 degree tapped, the forearm extends triceps muscle is normal.
angle. at the elbow joint.
2. Tap triceps tendon just
above the elbow.
1. Flex client’s arm at 45 Flexion of forearm Forearm flexion is present. Normal forearm flexion.
degree angle and place
Brachioradialis on lap with the arm
semipronated.
2. Tap brachioradialis
tendon on thumb side
of the wrist.
1. Ask the client to sit in a Extension of leg below the The quadriceps muscle Normal leg extension and
chair or on edge of bed knee. contracts as the knee quadriceps muscle
Patellar with legs hanging stretches. contraction.
freely or in supine
position with knee
flexed.
2. Tap patellar tendon just
below the patella.
1. Ask client to sit with Plantar flexion of foot. Plantar flexion is present. The plantar flexion of the
 Achilles feet dangling and foot is normal.
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.
1. Position client’s ankle Bending of the toes downward. There is the presence of toe- The response is normal.
firmly against the bed. curling.
Plantar (Babinski) 2. Slowly stroke client’s
sole with the handle of
the reflex hammer.

Name: Ms. K
1. SKIN
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color Inspection Inspect variations in skin Color varies from light Skin color is light and There are no signs of
color under natural sunlight to to ruddy pink or dark uniform. abnormalities.
ensure accuracy findings. brown, depending on the
race. Color is uniform
except for sun exposed
areas or normally
 lighted pigmented areas
(nailbeds, palms, lips) in
dark skinned people.
Lesions Inspection Note for color, size, and Freckles, skin tags in No presence of in The client's skin is
anatomic location and elderly, and some types lesions, skin abrasions, smooth and no
distribution. of birthmarks and moles and scars. blemishes are present.
are normal.
Moles are also present
Palpation in the patient face and
Palpate lesions with finger
arms.
pads for mobility and contour
(flat, raised, or depressed) and
consistency (soft or durable)
Moisture Inspection Note amount and distribution Moisture varies with Skin is naturally moist, There are no
and Palpation activity, body and smooth and even. abnormalities present.
environmental
temperature, and
humidity in skin folds
and the axillae.
Temperature Palpation Palpate with dorsum of hand Temperature should be Skin temperature is Temperature is within
noting for uniformity of uniform and within 36.9°C normal range therefore
warmth. normal range. no fever is present.
Texture (quality, Palpation Palpate with finger pads in Texture is not uniform The skin is smooth and There are no
thickness, different areas like the palms and soles palms and soles are abnormalities present.
suppleness) are thicker than any thicker than any areas
areas. Wrinkled and of her skin.
leathery skin in the
elderly results from the
 normal aging. Process
with decreased collagen,
subcutaneous fats, and
sweat glands.

AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND

TO ASSESS INTERPRETATION

Mobility and turgor Palpation Assess mobility and turgor to Absence of indention is When pinched the skin There are no
(elasticity) measure elasticity of skin to dependent areas and the returned to the hand abnormalities present.
determine the degree of resilience of the skin within less than 2
hydration. spring back to its seconds. She has no
previous state after edema.
being pinched.
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
9. 3+ = deep/severe
(6mm)
10. 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/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color and Inspect Assess for color and Color varies from black Hair color is slightly There are no
Distribution distribution of scalp hair, to pale blonde based on brown. Body hair is abnormalities present.
eyebrows, eyelashes, and the amount of melanin equally distributed.
body surface. present.
Texture and oiliness Palpation Assess for the skin’s texture Thin, straight, coarse, Hair is straight, shiny Due to usage of
and oiliness with the use of thick, or curly. Hair is and resilient. shampoo or conditioner
palm. shiny and resilient that has no harmful
chemicals.
 infestation Inspection Assess for any presence of Free from any Hair is free from any There are no
infestation by examining the infestation. infestation. abnormalities present.
hair and scalp.

3. SCALP
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Scaliness and scars Inspection Part the hair repeatedly all The scalp should be The scalp of the client There are no
over the scalp and inspect for shiny and smooth is shiny and smooth abnormalities present.
scaliness and scars. without lesions, lumps, without any presences
or masses. of lesions, lumps, or
masses.
Tenderness, lesions, Palpation Place finger pads on the scalp Absence of redness or No redness and There are no
lumps, masses at the front and palpate down scaliness. scaliness present. abnormalities present.
the midline and each side for
Theres no palpated
tenderness, lesions, lumps, or
lesions, tenderness and
masses.
masses on the client’s
scalp.

4. NAILS
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color, shape, and Inspection Inspect for color and shape Nailbeds is highly Nail bed is pink with an No abnormalities
texture vascular with a pink angle of 160 degrees. present.
color in light skinned Nails are smooth and
clients and longitudinal firm upon palpation.
streaks of brown or
black pigmentation in
dark skinned clients.
Angle between
fingernail and base is
about 160 degrees.

Palpation Palpate nailbed for firmness

and texture
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.
Nailbed is firm
When pressure is The nails easily return Due to good blood flow
released from the nail, it to their normal pink in the body.
promptly returns to its color after the pressure
normal color. is released from the
nail.
Tissue surrounding the The tissue that Nail is strongly intact to
nail is intact. surrounds the nail is the tissue that surrounds
intact. the nail.

5. SKULL
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Shape and symmetry Inspection Inspect skull for shape,
symmetry, size in proportion
to body and position.
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.
6. FACE
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
Facial features Inspection Inspect facial features for
expression, shape, and
symmetry of eyebrows,
placement of nose, eyes, and
ears.
Edema and masses Inspection Inspect for any presence of
Rounded, symmetrical, The skull of the client The client's skull is
normocephalic, and is round and symmetrically
upright. symmetrical. movement and round.
Previous concussions
not apparent. This
indicates that the client
had no previous severe
head injuries.
Smooth, non-tender, free It is smooth, non- No abnormalities
of masses or tender, free of masses present.
depressions. or depressions.
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
May be oval, round, or Facial feature is oval No abnormalities
square. Symmetrical and has symmetrical present on the face.
features and movement. facial features and
movement.
No edema and masses No present edema and No abnormalities
 edema and masses masses. present on the face

7. EYES
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION

Visual Acuity Inspection Test visual acuity. Normal vision based on Eye color is black. She does not experience
the Snellen chart is 20/20 any blurry vision.
8. Position Snellen chart 20 Eye is normal,
at the distance of 20 feet
ft. in front of client. symmetrical, no
9. Remove corrective the normal eye can read
discharge and no
lenses, if appropriate. the chart).
presence of swelling.
10. Instruct client to cover
one eye and read lines Has 20/20 vision.
starting with top of chart
from left to right.
11. Note the line where client
reads more than half of
the letters.
12. Record results as a
fraction sc (without
correction), 20/ 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 The eye movement is No abnormalities
muscle movements: be symmetrical as both smooth and no jerking. present.
eyes follow the direction
9. Place the client in sitting
of the gaze and
position.
10. Instruct the client to hold converge on the held
head still. object as its moves
11. Ask the client to follow toward the nose.
an object with eyes.
12. Move objects with 6
fields of gaze.
***The 6 Fields of Gaze The upper eyelids cover The upper eyelids of Upon examination, the
only the uppermost part the patient exhibit no upper eyelids of the
7. Conjugate left lateral
of the iris and are free signs of nystagmus, patient remain stable
gaze
8. Left down and lateral from nystagmus indicating a lack of and without any
gaze (involuntary rhythmical involuntary and abnormal twitching or
9. Right down and lateral oscillation of the eyes). rhythmic movements in oscillations.
gaze A few beats of the eyes.
10. Conjugate right lateral nystagmus with extreme
gaze lateral gaze can be
11. Right up and lateral gaze normal.
12. Left up and lateral
13. Observe for parallel eye
movement.
14. Pause during upward and
lateral gaze field to detect
in voluntary rhythmic
oscillation of eyes.
15. Note position of upper
eyelid in relation to the
iris and eyelid bag 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.
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
External anatomical Inspection Observe upper eyelid.
structures
Check eyes and eyelids for
inflammation, crusting, edema Eyes and eyelids should
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.
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Upper eyelid should The upper eyelid No abnormalities
overlap iris. overlaps the iris. present.
The eyes and eyelids
be free from are free from any form
inflammation, crusting, of inflammation,
edema or masses. crusting, edema or
masses.
Lacrimal gland should The lacrimal gland is No abnormalities
not be palpable. not palpable. present.
Tears flow freely from
the lacrimal over the
Tears flow freely from
cornea and conjunctiva
the lacrimal gland over
to the lacrimal duct.
the cornea and
conjunctiva to the
lacrimal duct.
Inspection Inspect bulbar and palpebral Bulbar is transparent Bulbar is transparent No abnormalities
conjuctiva and sclera. with small blood with small blood present.
vessels. vessels.
d. Instruct client to look
upward while depressing Palpebral conjunctiva The Palpebral
lower lid with thumb. covering the inside of conjunctiva is pink and
e. Inspect for color, redness, the upper and lower moist. Sclera is white
swelling, exudates, or eyelids is pink and with some superficial
foreign bodies. moist. blood vessels.
f. Inspect cornea, lenses,
pupil, iris, and anterior Sclera is white with Corneas are moist,
chamber: some superficial blood shiny and clear. Lenses
1. Stand in front of vessels depending on the are transparent. Pupils
the client. race. are black, and round
2. Shine penlight with an equal diameter
directly on cornea.
of 3mm. The entire iris
3. Move light
laterally and view Corneas are moist, shiny illuminates when
cornea from that and clear. shining light laterally
angle; note color, too nasally.
Lenses are transparent.
discharge, and
lesions. Pupils are black, round
4. Look at pupil and and equal diameter,
note size and ranging from 2-6mm.
shape.
5. Shine penlight Entire iris should
directly on pupils illuminate when shining
to assess lens and light laterally too
color. nasally.
6. Look at iris for
size, and ability of
pupils to react to
 light.
7. Shine a light
obliquely through
anterior chamber
from lateral side
toward nasal side.
Inspection Test for papillary response to
light and reaction to
accommodation in dimly lit
room.
8. Instruct client to look
straight ahead.
9. Bring penlight from side
of the client’s face to
directly in front of the
pupil.
10. Note quickness or
response to light.
11. Shine light into same
eye observing for response
or pupil for equality of
size and repeat steps to the
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
Pupils should constrict The patient's pupils The patient's pupils
quickly in direct rapidly contract in exhibit a prompt and
response to light and the direct reaction to light, simultaneous
opposite pupil should and the corresponding constriction in response
also constrict. pupil on the opposite to direct exposure to
side also constrict. light. This coordinated
Pupil should be equal in
reaction is a healthy and
size. The size of the patient's
synchronized pupillary
pupil is equal.
Papillary response, indicative of
accommodation causes normal neurological
constriction in response function and visual
to objects that are near. pathways.
Pupillary dilatation
occurs when pupils
accommodate objects at
a distance, with
symmetrical
convergence of eyes.
 noting response of both
pupil.
14. Record results
PERRLA (pupils equal,
round, reactive to light
accommodation).

8. EARS
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
External ear Inspection Examine external ear, called Symmetrical, with upper The client’s ears are No abnormalities
the auricle or pinna for attachment at eye corner symmetrical, with present.
placement, symmetry, color, level, and is fleshed upper attachment at eye
discharge and swelling. colored. corner level, and
fleshed colored

Palpation Palpate the auricle between Firm, smooth, free from Ears are firm, smooth, There are no signs of
the thumb and index finger lesions and pain. and free from lesions abnormalities.
noting lesions or tenderness and pain.
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 The client should be The patient can hear The patient can hear
able to repeat whispered and able to repeat the properly.
5. Instruct the client to
 occlude one ear with words. whispered words.
finger and repeat the
words when heard.
6. Stand 1-2 feet away
from the client, out of
view to avoid client
from lip reading, and
softly whisper
numbers on side of the
ears. Increase voice
volume until client
identifies uttered
number.
7. Repeat procedure on
other ear.
8. Record results.

9. NOSE AND SINUSES

AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION

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
Located symmetrically, The client's nose is The client's nose is
midline of the face, and symmetrical, centered normal because it
is without swelling, on the face, and free of matches the rest of her
bleeding, lesions, or swelling, bleeding, face in color. Her nasal
masses. lesions, and masses. structure is smooth and
symmetric, and she does
not have any tenderness.
 the mouth and apply Each nostril is patent.
pressure on one nares
and breathe
d. Repeat test on
opposite nares.
Nasal cavities Inspection Inspect the nasal cavity with a Mucosa is pink or dull The mucosa is pink in The nasal mucosa of the
penlight: without swelling or color and free of edema client is pink, moist, and
polyps. and polyps The septum free of exudate,
d. Tilt client’s head in an
is intact and located in indicating that it is
extended position. Septum is midline and
e. Place non dominant the midline. normal. There are no
intact.
hand on client’s head discolorations,
There is no watery
using your thumb, and A small amount of clear swellings, or other
discharge.
lift the tip of the nose. watery discharge is abnormalities.
f. With the lit penlight, normal.
.
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 None-tender air filled There was no pain felt When the nasal sinuses
on frontal and maxillary areas cavities. while palpating the were palpated, no sinus
avoiding pressure on the eyes. frontal and maxillary pain was detected, and
sinuses. The client the client's nose was
Percuss area and note the
showed no signs of patterned with good
sound.
pain when palpated. airflow.
Resonant sound upon The client is able to
percussion. breathe freely.
 10. Mouth
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Breath Inspection Stand 12-18 inches in front of Breath should smell The client has a The client’s breath is
client and smell the breath. fresh. pleasant breath scent. free from halitosis,
which means normal.
The client doesn’t have
any lesions or
Observe lips for color,
Lips inflammation, and her
moisture, swelling, lesions
lips and mucosa are
c. Instruct client to open pink.
mouth and use tongue
depressor to retract Lips and mucosa should
buccal mucosa and be pink, firm, and moist
note color, hydration, without inflammation or
inflammation, or
lesions.
lesions.
d. 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 Gums are pink, smooth The client’s gums are The client’s gums are
and note color, edema, and moist. pink in color, moist and evenly colored.
retraction, bleeding and firm to touch.
lesions.
 Palpation Palpate gums with tongue
blade for texture
Ask client to clench teeth to
assess position and alignment
Teeth Inspection
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
size, texture, nodules,
or ulcerations.
6. Still with penlight,
inspect floor of mouth,
salivary glands, and
Palpation duct openings.
Grasp tongue with a gauze
and gently pull it to one side
and palpate full length of
Gums are firm.
Teeth are properly The client's teeth are The client's teeth are
aligned, smooth, white evenly spaced and decayed and thus not
and shiny. white to slightly normal.
yellowish in color, but
there is decay on the
side of her front teeth.
When protruded, tongue The client's tongue is The client's tongue
lays midline, medium pink and protrudes in appears to be in good
red or pink in color, the middle of his health, as she has a
moist and smooth along mouth. It is also moist medium-sized tongue. It
lateral margins, with and free of lesions. is pink and moist with
free mobility. papillae. There are no
lesions to be found. The
The dorsal surface is
tongue of the client
slightly rough (taste
provides string
buds) and free from
resistance.
lesions.
The ventral surface is
highly vascular, smooth,
moist, and free of
lesions.
 tongue.

AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND

TO ASSESS INTERPRETATION
Palate Inspection Inspect the soft and hard Palates are concave and The patient has a pink The client's palates
palate with a penlight: pink. and concave palate. appear to be normal.
The hard palate also Palate of the client is
c. Instruct client to Hard palate has ridges.
has ridges, whereas the pinkish, movable,
extend head backward
and hold mouth open. Soft Palate is smooth. soft palate is soft and spongy, and smooth.
d. Inspect the hard palate smooth to the touch.
(roof of mouth) and
soft palate for color,
shape, lesions.
Inspection Inspect pharynx using tongue With phonation, the soft The pharynx of the The client's pharynx is
depressor and penlight: palate and uvula rise client is pink and free normal. The uvula hangs
symmetrically. of lesions, and the freely in the midline.
f. Explain procedure to
Pharynx uvula is symmetrically There was no uvula or
client. The pharynx is pink,
g. Instruct client to tilt raised with a soft palate soft palate redness or
vascular, lesion free.
head back and open and phonation. exudates.
mouth. Tonsil size is evaluated
h. With non-dominant using the grading scale.
hand, place tongue
depressor on middle
third of tongue. With
the dominant hand,
shine light into back of
throat.
i. Instruct client to say
 “ah” and note position,
size, appearance of
tonsils and uvula.
j. Inform client of
eliciting gag reflex by
touching the posterior
1/3 of tongue with
tongue blade if palate
and uvula fail to rise
symmetrically with
phonation.

11. NECK
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Inspection Instruct client to: Muscles are The neck appears The distribution of
symmetrical with head symmetrical there’s no muscles and soft tissues
Symmetry and c. Flex chin to chest and
in central position. obvious signs of are similar on the left
Musculature to teach side and
shoulder to test asymmetry, tilting and and right sides
Movement though full
anterior deviation from the
range of motion without
sternocleidomastiod midline.
complaint of discomfort
muscle. Due to sun protection
or limitation. The skin color is brown
d. Hyperextend the neck and cleansing.
and uniform, skin
backward to test
texture is smooth and
posterior trapezia.
even.
Palpation Palpate lymph nodes and Lymph nodes should not The patient’s lymph There are no signs of
instruct client to relax and be palpable. Small, nodes are not palpable. abnormalities.
movable nodes are
 flex neck slightly forward. insignificant.
4. Stand in front of
seated client.
Lymph nodes 5. 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.
6. Note size, shape,
mobility, consistency
and tenderness.
Trachea Inspection Note for position. Midline position above The trachea is Indicates that the trachea
the suprasternal notch. positioned centrally in is properly positioned
the neck aligned with within the neck.
Palpation Place thumbs and index finger the midline of the body
on sides of trachea and apply
gentle pressure and palpate.
Palpation With client seated, assessment Thyroid cannot be There’s no visible or Thyroid gland appears
may be done with posterior visualized. palpable masses or to be in a normal size.
and anterior approach: enlargement of the
thyroid gland.
C. POSTERIOR
APPROACH It may or may not be
Thyroid No signs of tenderness.
1. Stand behind client felt.
and place thumbs
 on nape of neck and
bring fingers
interiorly around If felt, it should be
neck with their tips smooth, soft, non-tender
resting over tracheal and not enlarged.
rings.
2. Ask client to tilt
chin forward to
relax neck muscles
and swallow.
3. Palpate the isthmus
rise under fingers
and feel each lateral
lobe before and
while client
Auscultation 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
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/FEATURE TECHNIQUE SKILLS
TO ASSESS
Inspection Place client in sitting position
with arms folded across chest,
back exposed.
3. Assess shape and
symmetry by taking note
of the rate and rhythm of
Shape, symmetry, respirations, movement of
and diameter chest wall with deep
inspiration and full
expiration.
4. Estimate anteroposterior
diameter in proportion to
lateral diameter.
Lesions Palpation 5. Palpate for lesions or
areas of pain.
6. Palpate thoracic
expansion at 10th rib by
placing thumb close to
client’s spine and spread
hands over thorax. Note
divergence of thumbs;
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Respirations are quite, Respirations are quite Normal respiration.
effortless, and regular, and regular with 18
Chest rises as the lungs
with 12-20 breaths per breaths per minute.
fill with air and falls as
minute.
Chest rises and fall air expelled from the
Thorax rises and falls in during breathing. lungs.
unison with respiratory
cycle.
Ribs slope across and
down, without
movement or bulging in
the intercostals spaces.
Thumb should separate No signs of tenderness No abnormalities
an equal distance of 3- and lesions in posterior present.
5cm and in the same thorax.
direction during thoracic
Fremitus is equal and
expansion and meet in
moderate vibrations are
the midline on
noticed during speech.
expiration.
 feel for range and
symmetry of movement
during deep inhalation Posterior thorax is free
and full exhalation. from tenderness, lesions
7. Place ulnar aspect of open and pulsations.
hand at right apex of lung
and place hand at each
posterior thorax location. Fremitus is equal on
Then instruct client to say both sides of thorax,
“99” and palpate for strongest at the level of
tactile fremitus tracheal bifurcation.
(vibrations caused by
vibrations). Note areas of
increased and 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 Tapping of the This indicates that air is
moving hands from side resonant sound. posterior thorax of the present in the underlying
to side across the top of patient produces a lung tissue.
Sound Percussion each shoulder. Note sound resonant sound.
produced from each
percussion strike and
compare with
contralateral sound.
4. Continue downward and Identify contralateral
post lateral every other sound; bones create flat
intercostals space. Note sound. Thorax is more
 intensity, pitch, duration, resonant in children and
and quality of percussion. thin adults.
Breath sounds Auscultation 5. Place diaphragm of Posterior sound: The sound of the Indicates a normal
stethoscope on right lung vesicular and posterior and lateral breath sound.
apex. Instruct client to bronchovesicular. thorax, soft and low
inhale and exhale deeply pitched like a gentle
and slowly when breeze through leaves.
stethoscope is felt on the
Lateral sound: vesicular
back. Repeat on left lung
apex.
6. More downward every
other intercostals spaces A large chest will
and auscultate, placing produce decreased
stethoscope in the same breath sound.
position on both sides.
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/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
 TO ASSESS INTERPRETATION
Inspection Place client in sitting position Thorax rises and falls in The respiration rate is The respiration rate is
or supine position. Inspect unison with respiratory 17 bpm. The thorax will within the normal rate.
client’s chest for: cycle, ribs at 45 degrees rise and fall if it is The respiration is
Symmetry, rhythm angle with sternum. relaxed and quiet. relaxed quiet and in a
3. Symmetry and depth
and slope Inspiratory breath regular rhythm.
of movement.
4. Slope of ribs and sounds are not audible at
musculoskeletal a distance of more than
deformities. 2to 3 cm from mouth.
Tenderness, Palpation 4. Place fingerpads on Same normal findings There is no presence of There is no tenderness,
pulsation, masses right apex above the with posterior palpation. tenderness or pain pulsation and masses
and crepitance clavicle. Proceed palpated over the area. found after the
downward to each rib palpation of the client,
and intercostals space which is an indications
and note for of normal findings
tenderness, pulsation,
masses and crepitance. Fremitus is symmetric
Repeat on left side. and easily identified
Respiratory 5. Assess respiratory which is normal.
excursion excursion by placing
Fremitus is symmetric
thumbs along each
and easily identified. It
costal margin with
hands on lateral rib is equal on both sides.
cage. Instruct client to
inhale deeply; note for
divergence of thumbs
on expansion; feel
range and symmetry
of respiratory
Tactile Fremitus movement.
 6. Palpate for tactile
fremitus. Gently
displace female
breasts as necessary.
Percussion Percuss anterior surface by: Resonant sound over Percussion elicits Though percussions
lung tissue dullness over breast and auscultation, the
2. Percuss 2-3 strikes
(hyperresonance in tissue, the heart, and the symmetry and sound
along right lung apex
and repeat on left lung children and thin adults) liver. are found normal.
apex. Proceed Cardiac, liver, and
downward, percussing gastric silhouettes emit
in every ICS going dull sound.
from right to left in
same positions on both Ribs emit flat sound.
sides.

Symmetry and
sound Assess each thorax area:
5. Resonant lung filled.
6. Cardiac dullness: 3rd-
5th ICS left of sternum.
7. Liver dullness: place
finger parallel to upper
border of expected
liver dullness in right
midclavicular line;
percuss downward.
8. Gastric air bubble:
repeat procedure done
on liver dullness on
the left side.
 Auscultation Auscultate anterior surface by Tympany is detected No abnormalities are
instructing client to breath over the stomach, and detected.
Anterior sounds:
through the mouth and flatness is detected over
bronchial,
compares symmetrical areas the bony prominence.
bronchovesicular,
of lungs from above
vesicular.
downward:
A large chest will
4. Listen to breath
sounds and note produce decreased
intensity and identify breath sounds.
variations from
normal.
5. Identify any added
sounds by location on
chest wall and time in
the respiratory cycle.
6. If breath sounds are
diminished, ask client
to breath hard and fast
with mouth open.

13. CARDIOVASCULAR
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Arterial Pulses Palpation Compress the radial artery Normal Heart rate The patient’s pulse rate No abnormalities
with your index finger and is 89 beats per minute. present.
middle finger.
Heart Inspection Precordial Movement When the patient was No murmurs and extra No abnormalities
 1. Position the patient supine auscultated, the heart sounds such as S3 present.
with the head slightly elevated pulsation in the mitral and S4 sounds are heard,
2. Always examine from the area can be palpable and the mitral area can be
Palpation patient's right side. when no signs of palpated and there are
3. Palpate for point of irregular rhythm and no signs of irregular
maximal impulse. (Normally murmur sounds. rhythm.
located at 4th or fifth ics,
Auscultation 1mcl)
4. Listen with diaphragm at
the right 2nd ICS
5. Listen to the 2nd ICS near
the sternum.
6. 3rd, 4th, 5th ICS near
sternum
7. Listen for apex

Tissue perfusion Palpation Perform the Allen Test to Palms should turn pink The client’s results were No abnormalities
determine patency of radial promptly. normal, after the Allen present.
and ulnar arteries. Instruct test was performed the
client to rest hands on lap. color of the palms
1. Compress both the radial immediately returned to
and ulnar arteries. normal pink hue.
2. Firmly compress arteries
and instruct clients to open
their hands.
3. Note the color of the palms.
4. Release one artery and note
the color of the palm.
5. Repeat steps on other
arteries on the same hand.
 14. ABDOMEN
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Generalized Inspection Placing client in supine Contour is flat or The abdomen of the No abnormalities
appearance of position with knees flexed rounded and bilaterally patient appears flat, and present.
abdomen over a pillow, hands at side or symmetrical. the umbilicus is
over the chest, undrape depressed and beneath
patient from xiphoid process the abdominal surface.
to symphysis pubis to expose Umbilicus is depressed
abdomen. and beneath the
abdominal surface.
5. Inspect abdomen
from rib margin to
pubic bone and note
for contour and Visible peristalsis is
symmetry. slowly transverses the
6. Inspect umbilicus abdomen in slanting
for contour, location, downward movements
signs of as observed in thin
inflammation or client. Pulsations of the
hernia. abdominal aorta are
7. Observe for smooth, visible in the epigastric
even respiratory
area in thin clients.
movements.
8. Observe for surface
motions (visible
peristalsis)
Bowel sounds Auscultation Auscultate the bowel sounds High pitched sounds There are present of soft Upon auscultation
on the abdominal quadrants heard every 5 to 15 gurgling sounds on the gurgling sounds are
using the diaphragm of the seconds as intermittent patient’s abdomen presents which is
 stethoscope. gurgling sounds in all 4 considered normal.
quadrants as a result of
4. Begin by placing the
fluid and air movement
diaphragm on the
RLQ. Listen for a in GIT.
full minute to the
frequency and
character of bowel
movements.
5. Repeat same step
proceeding in Bowel sounds should
sequence to RUQ, always be heard at the
LUQ, and LLQ. ileocecal valve.
6. Listen at least for 5
minutes before
concluding the
absence of bowel
sounds.
Abdominal Percussion Begin percussion in RLQ, Tympany is heard Tympany over the The overall finding in
quadrants move upward to RUQ, cross because of air in the stomach, epigastric area, the percussion of the
over to LUQ, and down to stomach and intestines. and upper midline, and abdominal quadrant,
LLQ. Note when tympani Dullness is heard over dullness over the liver, a there is a presence of
changes to dullness. organs. full bladder. dullness over the liver
and the bladder which
is normal.

15. NEUROLOGIC SYSTEM

ASSESSMENT OF COMMON DEEP TENDON REFLEX
TYPE ASSESSMENT NORMAL REFLEX KEY FINDINGS ANALYSIS AND
 INTERPRETATION
4. Flex client’s arm No difficulties detected. The bicep reflex is
between 45 degree normal.
Biceps angle and 90 degree. There should be flexion of arm
5. Place thumb firmly on at elbow.
biceps tendon just
above the crease of
antecubital fossa.
6. Tap thumb with reflex
hammer.
Triceps 3. Flex client’s arm at 45 Extension of elbow Elbow stretch and the triceps The contraction of the
degree and 90 degree tightens triceps and the elbow
angle. extensions is normal.
4. Tap triceps tendon just
above the elbow.
3. Flex client’s arm at 45 Flexion of forearm Forearm flexion is present. Normal forearm flexion.
degree angle and place
Brachioradialis on lap with the arm
semipronated.
4. Tap brachioradialis
tendon on thumb side
of the wrist.
3. Ask the client to sit in a Extension of leg below the The quadriceps muscle Normal leg extension and
chair or on edge of bed knee. contracts as the knee quadriceps muscle
Patellar with legs hanging stretches. contraction.
freely or in supine
position with knee
flexed.
4. Tap patellar tendon just
below the patella.
3. Ask client to sit with Plantar flexion of foot. Plantar flexion is present. The plantar flexion of the
 Achilles feet dangling and foot is normal.
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.
3. Position client’s ankle Bending of the toes downward. There is the presence of toe- The response is normal.
firmly against the bed. curling.
Plantar (Babinski) 4. Slowly stroke client’s
sole with the handle of
the reflex hammer.

Name: Mr. N
1. SKIN
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color Inspection Inspect variations in skin Color varies from light Mr. N has an even There are no signs of
color under natural sunlight to to ruddy pink or dark brown skin color. abnormalities.
ensure accuracy findings. brown, depending on the
race. Color is uniform
except for sun exposed
areas or normally
lighted pigmented areas
(nailbeds, palms, lips) in
 dark skinned people.
Lesions Inspection Note for color, size, and Freckles, skin tags in Mr. N skin on the face Due to typical age-
anatomic location and elderly, and some types and hands, show signs related changes in these
distribution. of birthmarks and moles of aging, including fine areas.
are normal. lines and wrinkles.

Palpation
Palpate lesions with finger
pads for mobility and contour Moles are present in
(flat, raised, or depressed) and the patient back and
consistency (soft or durable) chest.
Moisture Inspection Note amount and distribution Moisture varies with Smooth skin, however Normal aging skin tends
and Palpation activity, body and there are areas that are to have reduced sebum
environmental dry especially on arms production, contributing
temperature, and and legs. to dryness.
humidity in skin folds
and the axillae.
Temperature Palpation Palpate with dorsum of hand Temperature should be 37 °C is the The patient temperature
noting for uniformity of uniform and within temperature of the is warm to touch.
warmth. normal range. client skin.
Texture (quality, Palpation Palpate with finger pads in Texture is not uniform The palms are soft, and There are no signs of
thickness, different areas like the palms and soles the soles are not thick. abnormalities.
suppleness) are thicker than any Wrinkles are also
areas. Wrinkled and present due to aging,
leathery skin in the but other than that,
elderly results from the there are no lesions.
normal aging. Process
with decreased collagen,
 subcutaneous fats, and
sweat glands.

AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND

TO ASSESS INTERPRETATION

Mobility and turgor Palpation Assess mobility and turgor to Absence of indention is After pinching the There are no signs of
(elasticity) measure elasticity of skin to dependent areas and the client's skin, it quickly abnormalities.
determine the degree of resilience of the skin turns back to its
hydration. spring back to its original position after 2
previous state after secs.
being pinched.
There are no signs of
Palpate dependent areas like
edema.
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)
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/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color and Inspect Assess for color and Color varies from black The patient’s hair is There are no
Distribution distribution of scalp hair, to pale blonde based on evenly distributed and abnormalities present.
eyebrows, eyelashes, and the amount of melanin black in color.
body surface. present.
Texture and oiliness Palpation Assess for the skin’s texture Thin, straight, coarse, The patient’s hair is There are no
and oiliness with the use of thick, or curly. Hair is shiny and thin abnormalities present.
palm. shiny and resilient
 infestation Inspection Assess for any presence of Free from any Hair is free from any There are no signs of
infestation by examining the infestation. infestation. abnormalities.
hair and scalp.

3. SCALP
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Scaliness and scars Inspection Part the hair repeatedly all The scalp should be The scalp appears clear There are no signs of
over the scalp and inspect for shiny and smooth and smooth, with no abnormalities.
scaliness and scars. without lesions, lumps, indications of lesions or
or masses. masses.
Tenderness, lesions, Palpation Place finger pads on the scalp Absence of redness or The patient's scalp is There are no signs of
lumps, masses at the front and palpate down scaliness. free from tenderness, abnormalities.
the midline and each side for lesions, bumps, or
tenderness, lesions, lumps, or masses.
masses.

4. NAILS
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color, shape, and Inspection Inspect for color and shape
texture
Palpation Palpate nailbed for firmness
and texture
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.
Nailbeds is highly The patient's nail bed is There are no signs of
vascular with a pink pink, and the nail is squ abnormalities.
color in light skinned are in shape.
clients and longitudinal
streaks of brown or
black pigmentation in
dark skinned clients.
Angle between
fingernail and base is Upon palpation, the
about 160 degrees. patient’s nails are
smooth and firm.
Nailbed is firm
When pressure is When the pressure is There are no signs of
released from the nail, it released from the nail, abnormalities.
promptly returns to its it instantly returns to its
normal color. original color in less
than 0.5 seconds.
Tissue surrounding the The tissue around the There are no signs of
nail is intact. nail is intact and free of abnormalities.
lesions.

5. SKULL
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Shape and symmetry Inspection Inspect skull for shape, Rounded, symmetrical, The patient’s skull is Upon examining the
symmetry, size in proportion normocephalic, and round, symmetrical and patient's skull reveals a
to body and position. upright. upright. well-proportioned and
symmetrical structure.

Contour, Masses, Palpation Palpate with fingerpads Smooth, non-tender, free The patient’s skull is There are no signs of
Depressions and beginning in frontal area and of masses or smooth and free from abnormalities.
Tenderness continuing over parietal, depressions. any signs of masses,
temporal, and occipital areas depressions or
for contour, masses, tenderness.
depressions, and tenderness.

6. FACE
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Facial features Inspection Inspect facial features for May be oval, round, or The patient has a There are no signs of
expression, shape, and square. Symmetrical square-shaped and abnormalities.
symmetry of eyebrows, features and movement. symmetrical face,
placement of nose, eyes, and featuring balanced and
ears. symmetrical features
like eyebrows, nose,
eyes, and ears.
Edema and masses Inspection Inspect for any presence of No edema and masses There is no presence of There are no signs of
edema and masses edema or masses on the abnormalities.
patient’s face.

7. EYES
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION

Visual Acuity Inspection Test visual acuity. Normal vision based on The patient’s eye color The patient’s good
the Snellen chart is 20/20 is black. vision indicates overall
15. Position Snellen chart 20
at the distance of 20 feet good eye health.
ft. in front of client.
16. Remove corrective the normal eye can read
lenses, if appropriate. the chart). Has a vision of 20/20 at
17. Instruct client to cover the distance of 20 feet.
one eye and read lines
starting with top of chart
from left to right.
18. Note the line where client
reads more than half of
the letters.
19. Record results as a
fraction sc (without
correction), 20/ distance
number, and the number
of the letters missed.
20. Repeat same steps for the
other eye.
21. If appropriate, repeat
steps with patient
 wearing the corrective
device.
Inspection Test eye for extraocular Eye movement should The patient There are no signs of
muscle movements: be symmetrical as both demonstrates smooth abnormalities.
eyes follow the direction eye movements, with
17. Place the client in sitting
of the gaze and both eyes tracking the
position.
18. Instruct the client to hold converge on the held direction of gaze
head still. object as its moves seamlessly and
19. Ask the client to follow toward the nose. converging on an
an object with eyes. object as it approaches
20. Move objects with 6 the nose.
fields of gaze.
***The 6 Fields of Gaze The upper eyelids cover The patient's upper Absence of involuntary
only the uppermost part eyelids show no and rhythmic eye
13. Conjugate left lateral
of the iris and are free evidence of nystagmus, movements indicates
gaze
14. Left down and lateral from nystagmus there is absence of normal eye function.
gaze (involuntary rhythmical involuntary and
15. Right down and lateral oscillation of the eyes). rhythmic eye
gaze A few beats of movements.
16. Conjugate right lateral nystagmus with extreme
gaze lateral gaze can be
17. Right up and lateral gaze normal.
18. Left up and lateral
21. Observe for parallel eye
movement.
22. Pause during upward and
lateral gaze field to detect
in voluntary rhythmic
oscillation of eyes.
23. Note position of upper
eyelid in relation to the
 iris and eyelid bag 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.

AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND

TO ASSESS
External anatomical Inspection Observe upper eyelid.
structures
Check eyes and eyelids for
inflammation, crusting, edema Eyes and eyelids should
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.
INTERPRETATION
Upper eyelid should The patient’s upper There are no signs of
overlap iris. eyelid margin overlaps abnormalities.
the iris.
be free from There is no presence of
inflammation, crusting, inflammation, edema,
edema or masses. or masses on the
patient’s eye and
eyelids.
The patient’s lacrimal
glands indicate no
redness or swelling.
Lacrimal gland should The patient’s lacrimal There are no signs of
not be palpable. gland is not palpated, abnormalities.
and the tears flow
easily from the lacrimal
gland to the lacrimal
 Inspect duct by palpating on Tears flow freely from duct through the cornea
the lacrimal sac and observing the lacrimal gland over and conjunctiva.
for regurgitation of fluid. the cornea and
conjunctiva to the
lacrimal duct.
Inspection Inspect bulbar and palpebral Bulbar is transparent The bulbar of the There are no signs of
conjuctiva and sclera. with small blood patient is clear and abnormalities.
vessels. characterized by the
g. Instruct client to look
presence of small blood
upward while depressing Palpebral conjunctiva
lower lid with thumb. vessels.
covering the inside of
h. Inspect for color, redness, the upper and lower The palpebral
swelling, exudates, or eyelids is pink and conjunctiva of the
foreign bodies. moist. patient is clear, moist
i. Inspect cornea, lenses,
and free from any
pupil, iris, and anterior Sclera is white with
swelling.
chamber: some superficial blood
1. Stand in front of vessels depending on the Sclera is white, and the
the client. race. cornea of the patient is
2. Shine penlight transparent, moist and
directly on cornea.
clear.
3. Move light
laterally and view Corneas are moist, shiny
cornea from that and clear.
angle; note color, Lenses are transparent.
discharge, and
lesions. Pupils are black, round
4. Look at pupil and and equal diameter,
note size and ranging from 2-6mm.
shape.
5. Shine penlight Entire iris should
 directly on pupils
to assess lens and
color.
6. Look at iris for
size, and ability of
pupils to react to
light.
7. Shine a light
obliquely through
anterior chamber
from lateral side
toward nasal side.
Inspection Test for papillary response to
light and reaction to
accommodation in dimly lit
room.
15. Instruct client to look
straight ahead.
16. Bring penlight from
side of the client’s face to
directly in front of the
pupil.
17. Note quickness or
response to light.
18. Shine light into same
eye observing for response
or pupil for equality of
size and repeat steps to the
other eye.
19. Instruct client to gaze
at your finger held 4-6
illuminate when shining
light laterally too
nasally.
Pupils should constrict The patient's pupils The patient's pupils
quickly in direct swiftly constrict in quickly and
response to light and the response to direct light, simultaneously constrict
opposite pupil should and the corresponding when exposed to light,
also constrict. pupil on the opposite indicating a healthy and
side also narrows. synchronized pupillary
Pupil should be equal in
response associated with
size. The size of the patient's
normal neurological
pupil is equal.
Papillary function and visual
accommodation causes pathways.
constriction in response
to objects that are near.
Pupillary dilatation
occurs when pupils
accommodate objects at
a distance, with
symmetrical
 inches from her nose then convergence of eyes.
to glance at a distant
object while 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/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
External ear Inspection Examine external ear, called Symmetrical, with upper The patient's ears are No abnormalities are
the auricle or pinna for attachment at eye corner symmetrical in size, observed upon
placement, symmetry, color, level, and is fleshed with the auricle inspection.
discharge and swelling. colored. aligning with the corner
of the eye, and the
color of his ears
complements his skin
tone.
 Palpation Palpate the auricle between Firm, smooth, free from The auricle and pinna There are no signs of
the thumb and index finger lesions and pain. of the patient is abnormalities.
noting lesions or tenderness smooth, firm and free
by moving auricle up and from any lesions or
down, same with the mastoid swelling.
tip.
Press inward on tragus noting
any tenderness.
Auditory acuity Inspection The Whispered Voice Test The client should be The patient’s hearing is There are no signs of
able to repeat whispered excellent and can abnormalities.
9. Instruct the client to
words. repeat whispered
occlude one ear with
finger and repeat the words.
words when heard.
10. Stand 1-2 feet away
from the client, out of
view to avoid client
from lip reading, and
softly whisper
numbers on side of the
ears. Increase voice
volume until client
identifies uttered
number.
11. Repeat procedure on
other ear.
12. Record results.

9. NOSE AND SINUSES

AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
Nose Inspection Inspect the nose for
symmetry, deformity, flaring,
or inflammation and
discharge from the nares.
Test patency of each nostril:
e. Instruct client to close
the mouth and apply
pressure on one nares
and breathe
f. Repeat test on
opposite nares.
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
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Located symmetrically, The patient's nose is The patient's nose is
midline of the face, and symmetrical, centrally aligned and
is without swelling, positioned at the center symmetrical, presenting
bleeding, lesions, or of the face, and shows no evidence of lesions,
masses. no signs of lesions, swelling, or bleeding.
swelling, or bleeding. Overall, the nasal
examination indicates a
The patient’s nostril is
Each nostril is patent. normal and healthy
patent.
condition.
Mucosa is pink or dull The patient's septum is There are no signs of
without swelling or intact and positioned at abnormalities.
polyps. the midline, with pink
mucosa and no
Septum is midline and
indications of bleeding
intact.
or swelling.
A small amount of clear
watery discharge is
normal.
 discharge.
Nasal sinuses Palpation Apply gentle upward pressure
on frontal and maxillary areas
avoiding pressure on the eyes.
Percuss area and note the
sound.
10. Mouth
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
Breath Inspection Stand 12-18 inches in front of
client and smell the breath.
Observe lips for color,
Lips
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
None-tender air-filled Upon palpation, there There are no signs of
cavities. is no sensitivity or abnormalities.
discomfort in the nasal
sinuses when touched.
There is resonant sound
Resonant sound upon upon percussion.
percussion.
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Breath should smell The patient's breath has Due to poor oral
fresh. an unpleasant odor. hygiene.
The patient's lips are The lips appear dry,
brown in color, dry, and which indicates lack of
free from any lesion. moisture and there are
no visible lesions or
abnormalities present.
Lips and mucosa should
be pink, firm, and moist
without inflammation or
lesions.
 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
assess position and alignment
Teeth Inspection
with the use of a tongue
depressor, expose molars and
note for tartar, cavities,
extraction and color.
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
size, texture, nodules,
Gums are pink, smooth The patient's gums are There are no signs of
and moist. pink, moist and firm. abnormalities.
Gums are firm.
Teeth are properly The patient's teeth are Upon inspection it
aligned, smooth, white not properly aligned, indicates dental
and shiny. with a yellowish color, irregularities, potential
and there are spaces issues with oral hygiene,
between each tooth. and variations in tooth
development.
When protruded, tongue The patient's tongue is The dorsal surface of the
lays midline, medium centrally positioned, tongue appears smooth
red or pink in color, and the upper surface is and devoid of any
moist and smooth along smooth without any lesions or abnormalities.
lateral margins, with lesions.
free mobility.
The patient's tongue
The dorsal surface is color is pink and is
slightly rough (taste
smooth and moist in
buds) and free from
 or ulcerations.
9. Still with penlight,
inspect floor of mouth,
salivary glands, and
duct openings.
Palpation Grasp tongue with a gauze
and gently pull it to one side
and palpate full length of
tongue.
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
Palate Inspection Inspect the soft and hard
palate with a penlight:
e. Instruct client to
extend head backward
and hold mouth open.
f. Inspect the hard palate
(roof of mouth) and
soft palate for color,
shape, lesions.
Inspection Inspect pharynx using tongue
depressor and penlight:
k. Explain procedure to
Pharynx
client.
l. Instruct client to tilt
head back and open
mouth.
lesions.
texture.
The ventral surface is
highly vascular, smooth,
moist, and free of
lesions.
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Palates are concave and The patient's palates There are no signs of
pink. have a concave shape, abnormalities.
and the soft palate is
Hard palate has ridges.
smooth, showing a
Soft Palate is smooth. light pink color.
The patient's hard
palate has ridges and is
firm in texture.
With phonation, the soft The patient's pharynx Upon inspection it is
palate and uvula rise and tonsil are pink in noted that the patient's
symmetrically. color and free from any pharynx and tonsils
lesions. exhibit a normal and
The pharynx is pink,
healthy appearance. The
vascular, lesion free.
coloration is described
Tonsil size is evaluated as pink, which is
 m. With non-dominant using the grading scale. indicative of the typical
hand, place tongue hue of these structures.
depressor on middle
third of tongue. With
the dominant hand,
shine light into back of
throat.
n. Instruct client to say
“ah” and note position,
size, appearance of
tonsils and uvula.
o. Inform client of
eliciting gag reflex by
touching the posterior
1/3 of tongue with
tongue blade if palate
and uvula fail to rise
symmetrically with
phonation.

11. NECK
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Inspection Instruct client to: Muscles are The patient's muscles We observed that the
symmetrical with head exhibit symmetry, and patient's neck
Symmetry and e. Flex chin to chest and
in central position. the head is centrally demonstrates
Musculature to teach side and
shoulder to test positioned. unrestricted movement,
Movement though full
anterior and there are no
range of motion without The patient's neck
sternocleidomastiod reported complaints of
complaint of discomfort movement can move
 muscle. or limitation. freely without any discomfort.
f. Hyperextend the neck complaints of
backward to test discomfort.
posterior trapezia.

Palpation Palpate lymph nodes and Lymph nodes should not The patient’s lymph There are no signs of
instruct client to relax and be palpable. Small, nodes are not palpable. abnormalities.
flex neck slightly forward. movable nodes are
insignificant.
7. Stand in front of
seated client.
8. Methodically palpate
Lymph nodes 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. Midline position above The patient’s trachea is We observed that the
the suprasternal notch. located in a midline patient's trachea is
position above the appropriately situated in
Palpation Place thumbs and index finger suprasternal notch. And the midline position
on sides of trachea and apply there is no pain upon above the suprasternal
gentle pressure and palpate. palpation. notch. And there is no
reported pain upon
 palpation, indicating that
the trachea is not tender
or sensitive to touch.
Palpation With client seated, assessment Thyroid cannot be The patient's thyroid is There are no signs of
may be done with posterior visualized. not swelling and has a abnormalities.
and anterior approach: soft texture upon
palpation.
E. POSTERIOR
APPROACH It may or may not be
Thyroid No bruits on
1. Stand behind client felt.
auscultation.
and place thumbs
on nape of neck and
bring fingers If felt, it should be
interiorly around smooth, soft, non tender
neck with their tips and not enlarged.
resting over tracheal
rings.
2. Ask client to tilt
chin forward to
relax neck muscles
and swallow.
3. Palpate the isthmus
rise under fingers
and feel each lateral
lobe before and
while client
Auscultation 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
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/FEATURE TECHNIQUE SKILLS
TO ASSESS
Inspection Place client in sitting position
with arms folded across chest,
back exposed.
5. Assess shape and
symmetry by taking note
of the rate and rhythm of
Shape, symmetry, respirations, movement of
and diameter chest wall with deep
inspiration and full
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Respirations are quite, The breathing rate is 19 Upon examination,
effortless, and regular, breaths per minute. The normal breathing rate,
with 12-20 breaths per chest moves smoothly smooth chest movement
minute. and silently during both during respiration are
inhalation and normal, and the absence
Thorax rises and falls in
exhalation, and no of deformities upon
unison with respiratory
deformities are palpation is also normal.
cycle.
identified upon
Ribs slope across and palpation.
 expiration. down, without
6. Estimate anteroposterior movement or bulging in
diameter in proportion to the intercostals spaces.
lateral diameter.
Lesions Palpation 9. Palpate for lesions or Thumb should separate No signs of tenderness The findings indicates
areas of pain. an equal distance of 3- and lesions in posterior that there are no
10. Palpate thoracic 5cm and in the same thorax noticeable
expansion at 10th rib by direction during thoracic abnormalities, skin
placing thumb close to expansion and meet in irregularities, or areas of
client’s spine and spread the midline on discomfort on the back
Fremitus is symmetric
hands over thorax. Note
expiration. and easily identified in of the thoracic region.
divergence of thumbs;
feel for range and the upper region of the
symmetry of movement lungs. It is equal on
during deep inhalation Posterior thorax is free both sides of the
and full exhalation. from tenderness, lesions thorax.
11. Place ulnar aspect of open and pulsations.
hand at right apex of lung
and place hand at each
posterior thorax location. Fremitus is equal on
Then instruct client to say both sides of thorax,
“99” and palpate for strongest at the level of
tactile fremitus
tracheal bifurcation.
(vibrations caused by
vibrations). Note areas of
increased and decreased
fremitus.
12. 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.
5. Start at lung apices by Air filled lungs create a Upon percussion, The presence of
moving hands from side resonant sound. resonant sound is resonant sounds during
to side across the top of heard. percussion on the thorax
Sound Percussion each shoulder. Note sound and lung assessment is a
produced from each positive indication.
percussion strike and Resonance is a normal
compare with
and expected sound,
contralateral sound.
Identify contralateral suggesting that the
6. Continue downward and
post lateral every other sound; bones create flat underlying lung tissue is
intercostals space. Note sound. Thorax is more air-filled and healthy.
intensity, pitch, duration, resonant in children and
and quality of percussion. thin adults.
Breath sounds Auscultation 9. Place diaphragm of Posterior sound: No adventitious Upon auscultation, there
stethoscope on right lung vesicular and sounds, such as is no abnormal sounds,
apex. Instruct client to bronchovesicular. crackles or wheezes are such as crackles or
inhale and exhale deeply auscultated. wheezes, were detected.
and slowly when
stethoscope is felt on the
Lateral sound: vesicular
back. Repeat on left lung
apex.
10. More downward every
other intercostals spaces A large chest will
and auscultate, placing produce decreased
stethoscope in the same breath sound.
position on both sides.
11. 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.
12. Repeat last step on the left
side.

B. ANTERIOR THORAX
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Inspection Place client in sitting position Thorax rises and falls in The respiration rate is Upon examination,
or supine position. Inspect unison with respiratory 18 breaths per minute. normal breathing rate,
client’s chest for: cycle, ribs at 45 degree The thorax moves smooth chest
Symmetry, rhythm angle with sternum. smoothly and quietly movement during
5. Symmetry and depth
and slope Inspiratory breath during inhalation and respiration are normal,
of movement.
6. Slope of ribs and sounds are not audible at exhalation. and the absence of
musculoskeletal a distance of more than deformities upon
deformities. 2to 3 cm from mouth. palpation is also
normal.
Tenderness, Palpation 7. Place fingerpads on Same normal findings There is no presence of The findings indicates
pulsation, masses right apex above the with posterior palpation. tenderness or pain that there are no
and crepitance clavicle. Proceed palpated over the area. noticeable
downward to each rib abnormalities, skin
and intercostals space irregularities, or areas
and note for of discomfort.
tenderness, pulsation,
masses and crepitance.
 Repeat on left side.
8. Assess respiratory
Respiratory excursion by placing
excursion thumbs along each Fremitus is symmetric Fremitus is symmetric
costal margin with and easily identified. It and easily identified
hands on lateral rib
is equal on both sides. which is normal.
cage. Instruct client to
inhale deeply; note for
divergence of thumbs
on expansion; feel
range and symmetry
of respiratory
movement.
Tactile Fremitus 9. Palpate for tactile
fremitus. Gently
displace female
breasts as necessary.
Percussion Percuss anterior surface by: Resonant sound over Percussion elicits Upon percussion and
lung tissue dullness over breast auscultation, the
3. Percuss 2-3 strikes
(hyperresonance in tissue, the heart, and the symmetry and sound
along right lung apex
and repeat on left lung children and thin adults) liver. are found normal.
apex. Proceed Cardiac, liver, and
downward, percussing gastric silhouettes emit
in every ICS going dull sound.
from right to left in
same positions on both Ribs emit flat sound.
sides.

Symmetry and
sound Assess each thorax area:
9. Resonant lung filled.
 10. Cardiac dullness: 3rd-
5th ICS left of sternum.
11. Liver dullness: place
finger parallel to upper
border of expected
liver dullness in right
midclavicular line;
percuss downward.
12. Gastric air bubble:
repeat procedure done
on liver dullness on
the left side.

Auscultate anterior surface by Anterior sounds:

instructing client to breath bronchial,
Auscultation Tympany is detected There are no signs of
through the mouth and bronchovesicular,
over the stomach, and abnormalities.
compares symmetrical areas vesicular.
flatness is detected over
of lungs from above A large chest will the bony prominence.
downward: produce decreased
7. Listen to breath breath sounds.
sounds and note
intensity and identify
variations from
normal.
8. Identify any added
sounds by location on
chest wall and time in
the respiratory cycle.
9. If breath sounds are
diminished, ask client
 to breath hard and fast
with mouth open.
13. CARDIOVASCULAR
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
Arterial Pulses Palpation Compress the radial artery
with your index finger and
middle finger.
Heart Inspection Precordial Movement
1. Position the patient supine
with the head slightly elevated
2. Always examine from the
Palpation patient's right side.
3. Palpate for point of
maximal impulse. (Normally
located at 4th or fifth ics,
1mcl)
Auscultation 4. Listen with diaphragm at
the right 2nd ICS
5. Listen to the 2nd ICS near
the sternum.
6. 3rd, 4th, 5th ICS near
sternum
7. Listen for apex
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Normal Heart rate Upon palpation, the Pulse rate of 96bpm
patient’s pulse rate is 96 falls within a moderate
beats per minute. range and is generally
considered within the
normal adult heart rate
range.
When the patient was Upon inspection, the There are no signs of
auscultated, the chest appears abnormalities.
pulsation in the mitral symmetrical without
area can be palpable and visible abnormalities or
when no signs of deformities.
irregular rhythm and
murmur sounds.
Upon palpation, the
pulse is regular and
strong, and the point of
maximal impulse is
palpable at the apex,
usually at the fifth
intercostal space in the
midclavicular line.
 Upon auscultation, heart
sounds are clear and
well-defined.

Tissue perfusion Palpation Perform the Allen Test to Palms should turn pink The palm and fingers There are no signs of
determine patency of radial promptly. quickly regain their abnormalities.
and ulnar arteries. Instruct normal color, indicating
client to rest hands on lap. good blood flow through
1. Compress both the radial the released artery.
and ulnar arteries.
2. Firmly compress arteries
and instruct clients to open
their hands.
3. Note the color of the palms.
4. Release one artery and note
the color of the palm.
5. Repeat steps on other
arteries on the same hand.

14. ABDOMEN
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Generalized Inspection Placing client in supine Contour is flat or The patient’s abdomen The patient's abdomen
appearance of position with knees flexed rounded and bilaterally is evenly round. is evenly round
abdomen over a pillow, hands at side or symmetrical. indicates a normal
over the chest, undrape distribution of
patient from xiphoid process The patient’s umbilicus abdominal content
to symphysis pubis to expose Umbilicus is depressed is in the midline, and the without significant
 abdomen. and beneath the skin color is same to the asymmetry or bulging.
abdominal surface. surrounding abdominal
9. Inspect abdomen
skin tone.
from rib margin to
pubic bone and note There are no signs of
for contour and Visible peristalsis is abnormalities on the
symmetry. slowly transverses the The patient’s abdomen abdomen of the client.
10. Inspect umbilicus abdomen in slanting is smooth and it is even
for contour, location, downward movements respiratory movements.
signs of as observed in thin No abnormal
inflammation or client. Pulsations of the respiratory movements
hernia. abdominal aorta are are observed.
11. Observe for smooth, visible in the epigastric
even respiratory area in thin clients.
movements.
12. Observe for surface
motions (visible
peristalsis)
Bowel sounds Auscultation Auscultate the bowel sounds High pitched sounds Bowel sounds are The presence of audible
on the abdominal quadrants heard every 5 to 15 audible in various bowel sounds in
using the diaphragm of the seconds as intermittent abdominal quadrants, as various abdominal
stethoscope. gurgling sounds in all 4 they represent the quadrants indicates
quadrants as a result of movement of contents normal gastrointestinal
7. Begin by placing the
fluid and air movement through the stomach. motility.
diaphragm on the
RLQ. Listen for a in GIT.
full minute to the
frequency and
character of bowel
movements.
8. Repeat same step
proceeding in Bowel sounds should
sequence to RUQ,
 LUQ, and LLQ. always be heard at the
9. Listen at least for 5 ileocecal valve.
minutes before
concluding the
absence of bowel
sounds.
Abdominal Percussion Begin percussion in RLQ, Tympany is heard Tympanic sounds are Tympanic sounds over
quadrants move upward to RUQ, cross because of air in the over air-filled structures air-filled structures
over to LUQ, and down to stomach and intestines. like the stomach and such as the stomach
LLQ. Note when tympani Dullness is heard over intestines and a hollow, and intestines indicate
changes to dullness. organs. drum-like sound is normal findings during
produced upon abdominal percussion.
percussion.

15. NEUROLOGIC SYSTEM

ASSESSMENT OF COMMON DEEP TENDON REFLEX
TYPE ASSESSMENT NORMAL REFLEX KEY FINDINGS ANALYSIS AND
INTERPRETATION
7. Flex client’s arm No difficulties detected. The bicep reflex is
between 45 degree normal.
Biceps angle and 90 degree. There should be flexion of arm
8. Place thumb firmly on at elbow.
biceps tendon just
above the crease of
antecubital fossa.
9. Tap thumb with reflex
 hammer.
Triceps 5. Flex client’s arm at 45 Extension of elbow When the triceps tendon is The contraction of the
degree and 90 degree tapped, the forearm extends triceps muscle is normal.
angle. at the elbow joint.
6. Tap triceps tendon just
above the elbow.
5. Flex client’s arm at 45 Flexion of forearm Forearm flexion is present. Normal forearm flexion.
degree angle and place
Brachioradialis on lap with the arm
semipronated.
6. Tap brachioradialis
tendon on thumb side
of the wrist.
5. Ask the client to sit in a Extension of leg below the The quadriceps muscle Normal leg extension and
chair or on edge of bed knee. contracts as the knee quadriceps muscle
Patellar with legs hanging stretches. contraction.
freely or in supine
position with knee
flexed.
6. Tap patellar tendon just
below the patella.
5. Ask client to sit with Plantar flexion of foot. Plantar flexion is present. The plantar flexion of the
feet dangling and foot is normal.
Achilles partially dorsiflexed or
in a supine position
with legs flexed at knee
and thigh externally
rotated.
6. Tap the Achilles tendon
just above the heel.
5. Position client’s ankle Bending of the toes downward. There is the presence of toe- The response is normal.
firmly against the bed.
Plantar (Babinski) 6. Slowly stroke client’s curling.
sole with the handle of
the reflex hammer.

Name: Ms. M (pregnant 4 months)

1. SKIN
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color Inspection Inspect variations in skin Color varies from light Ms. M has a brown There are no signs of
color under natural sunlight to to ruddy pink or dark skin color. abnormalities.
ensure accuracy findings. brown, depending on the
race. Color is uniform
except for sun exposed
areas or normally
lighted pigmented areas
(nailbeds, palms, lips) in
dark skinned people.
Lesions Inspection Note for color, size, and Freckles, skin tags in Ms. M has a stretch Striae and linea nigra
anatomic location and elderly, and some types mark or striae and dark are present due to
distribution. of birthmarks and moles line or linea nigra on pregnancy.
are normal. the bottom area of her
belly.
Palpation
Palpate lesions with finger
pads for mobility and contour
(flat, raised, or depressed) and Moles are present in
consistency (soft or durable) the patient face and
chest.
Moisture Inspection Note amount and distribution Moisture varies with The patient has soft The patient skin is dry
and Palpation activity, body and skin, however there are due to hormonal
environmental areas that are dry changes.
temperature, and especially in her face
humidity in skin folds and abdomen.
and the axillae.
Temperature Palpation Palpate with dorsum of hand Temperature should be 36.6 °C is the The patient temperature
 noting for uniformity of uniform and within temperature of the is warm to touch.
warmth. normal range. client skin.
Texture (quality, Palpation Palpate with finger pads in Texture is not uniform The palms and soles There are no signs of
thickness, different areas like the palms and soles are thicker than any abnormalities.
suppleness) are thicker than any other areas of her skin.
areas. Wrinkled and
leathery skin in the
elderly results from the
normal aging. Process
with decreased collagen,
subcutaneous fats, and
sweat glands.

AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND

TO ASSESS INTERPRETATION
Mobility and turgor Palpation Assess mobility and turgor to Absence of indention is After pinching the There are no signs of
(elasticity) measure elasticity of skin to dependent areas and the client's skin, it quickly abnormalities.
determine the degree of resilience of the skin turns back to its
hydration. spring back to its original position after
previous state after 0.2 secs.
being pinched.
There are no signs of
Palpate dependent areas like
edema.
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:
16. 0 = no pitting
17. 1+ = trace/mild
(2mm) pitting
18. 2+ = moderate
(4mm) pitting
19. 3+ = deep/severe
(6mm)
20. 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/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color and Inspect Assess for color and Color varies from black The patient’s hair is There are no signs of
Distribution distribution of scalp hair, to pale blonde based on evenly distributed and abnormalities.
eyebrows, eyelashes, and the amount of melanin black in color.
body surface. present.
Texture and oiliness Palpation Assess for the skin’s texture Thin, straight, coarse, The patient’s hair is There are no signs of
and oiliness with the use of thick, or curly. Hair is thick, and shiny. abnormalities.
palm. shiny and resilient
infestation Inspection Assess for any presence of Free from any There is no presence of There are no signs of
infestation by examining the infestation. any infestation. abnormalities.
hair and scalp.

3. SCALP
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Scaliness and scars Inspection Part the hair repeatedly all The scalp should be The scalp is clean and There are no signs of
 over the scalp and inspect for
scaliness and scars.
Tenderness, lesions, Palpation Place finger pads on the scalp
lumps, masses at the front and palpate down
the midline and each side for
tenderness, lesions, lumps, or
masses.
shiny and smooth smooth, there is no abnormalities.
without lesions, lumps, signs of any lesions or
or masses. masses.
Absence of redness or There is no tenderness, There are no signs of
scaliness. lesions, lumps, or abnormalities.
masses on the patient’s
scalp.

4. NAILS
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color, shape, and Inspection Inspect for color and shape Nailbeds is highly The patients nail bed is There are no signs of
texture vascular with a pink pink and the shape of abnormalities.
color in light skinned the nail is round.
clients and longitudinal
streaks of brown or
black pigmentation in
dark skinned clients.
Angle between
fingernail and base is
about 160 degrees.
Upon palpation, the
Palpation Palpate nailbed for firmness patient’s nails are
 and texture
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.
Nailbed is firm smooth and firm.
When pressure is Upon the release of There are no signs of
released from the nail, it pressure from the nail, abnormalities.
promptly returns to its it quickly returns to its
normal color. usual color in less than
1 second.
Tissue surrounding the The tissue surrounding There are no signs of
nail is intact. the nail remains intact abnormalities.
and free from any
lesions.

5. SKULL
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Shape and symmetry Inspection Inspect skull for shape, Rounded, symmetrical, The patient’s skull is Upon examining the
symmetry, size in proportion normocephalic, and round and symmetrical. patient's skull reveals a
to body and position. upright. well-proportioned and
symmetrical structure.
 Contour, Masses, Palpation Palpate with fingerpads Smooth, non-tender, free The patient’s skull is There are no signs of
Depressions and beginning in frontal area and of masses or smooth and free from abnormalities.
Tenderness continuing over parietal, depressions. any signs of masses,
temporal, and occipital areas depressions or
for contour, masses, tenderness.
depressions, and tenderness.

6. FACE
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Facial features Inspection Inspect facial features for May be oval, round, or The patient's face is There are no signs of
expression, shape, and square. Symmetrical round and symmetrical abnormalities.
symmetry of eyebrows, features and movement. in shape, with
placement of nose, eyes, and symmetrical features
ears. such as eyebrows, nose,
eyes, and ears.
Edema and masses Inspection Inspect for any presence of No edema and masses There is no presence of There are no signs of
edema and masses edema or masses on the abnormalities.
patient’s face.

7. EYES
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION

Visual Acuity Inspection Test visual acuity. Normal vision based on The patient's visual The patient has normal
the Snellen chart is 20/20 acuity at a distance of visual acuity at a
22. Position Snellen chart 20
at the distance of 20 feet 18 feet is recorded as distance of 18 feet,
ft. in front of client.
23. Remove corrective the normal eye can read 20/20. which is indicative of
lenses, if appropriate. the chart). good eye health and
24. Instruct client to cover accurate distance vision.
one eye and read lines
starting with top of chart
from left to right.
25. Note the line where client
reads more than half of
the letters.
26. Record results as a
fraction sc (without
correction), 20/ distance
number, and the number
of the letters missed.
27. Repeat same steps for the
other eye.
28. If appropriate, repeat
steps with patient
wearing the corrective
device.
Inspection Test eye for extraocular Eye movement should The smooth eye There are no signs of
muscle movements: be symmetrical as both movement of the abnormalities.
eyes follow the direction patient is evident, with
25. Place the client in sitting
of the gaze and both eyes smoothly
position.
26. Instruct the client to hold converge on the held tracking the gaze
 head still. object as its moves direction and
27. Ask the client to follow toward the nose. converging on the
an object with eyes. object as it moves
28. Move objects with 6 closer to the nose.
fields of gaze.
***The 6 Fields of Gaze The upper eyelids cover The upper eyelids of Upon examination, the
only the uppermost part the patient exhibit no upper eyelids of the
19. Conjugate left lateral
of the iris and are free signs of nystagmus, patient remain stable
gaze
20. Left down and lateral from nystagmus indicating a lack of and without any
gaze (involuntary rhythmical involuntary and abnormal twitching or
21. Right down and lateral oscillation of the eyes). rhythmic movements in oscillations.
gaze A few beats of the eyes.
22. Conjugate right lateral nystagmus with extreme
gaze lateral gaze can be
23. Right up and lateral gaze normal.
24. Left up and lateral
29. Observe for parallel eye
movement.
30. Pause during upward and
lateral gaze field to detect
in voluntary rhythmic
oscillation of eyes.
31. Note position of upper
eyelid in relation to the
iris and eyelid bag as the
client’s eye move from
up and down.
32. Move object forward to
about 5 inches in front of
the client’s nose at the
midline and observe for
 convergence, and record
result.
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
External anatomical Inspection Observe upper eyelid.
structures
Check eyes and eyelids for
inflammation, crusting, edema Eyes and eyelids should
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.
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Upper eyelid should The patient’s upper There are no signs of
overlap iris. eyelid margin overlaps abnormalities.
the iris.
be free from There is no presence of
inflammation, crusting, inflammation, edema,
edema or masses. or masses on the
patient’s eye and
eyelids.
The patient’s lacrimal
glands indicate no
redness or swelling.
Lacrimal gland should The patient’s lacrimal There are no signs of
not be palpable. gland is not palpated, abnormalities.
and the tears flow
easily from the lacrimal
Tears flow freely from gland to the lacrimal
the lacrimal gland over duct through the cornea
the cornea and and conjunctiva.
conjunctiva to the
lacrimal duct.
Bulbar is transparent The bulbar of the There are no signs of
with small blood patient is clear and
j. Instruct client to look vessels. characterized by the abnormalities.
upward while depressing presence of small blood
lower lid with thumb. Palpebral conjunctiva
vessels.
k. Inspect for color, redness, covering the inside of
swelling, exudates, or the upper and lower The palpebral
foreign bodies. eyelids is pink and conjunctiva of the
l. Inspect cornea, lenses, moist. patient is clear, moist
pupil, iris, and anterior and free from any
chamber: Sclera is white with
swelling.
1. Stand in front of some superficial blood
the client. vessels depending on the Sclera is white, and the
2. Shine penlight race. cornea of the patient is
directly on cornea. transparent, moist and
3. Move light clear.
laterally and view Corneas are moist, shiny
cornea from that and clear.
angle; note color,
discharge, and Lenses are transparent.
lesions.
4. Look at pupil and Pupils are black, round
note size and and equal diameter,
shape. ranging from 2-6mm.
5. Shine penlight Entire iris should
directly on pupils
illuminate when shining
to assess lens and
color. light laterally too
6. Look at iris for nasally.
size, and ability of
pupils to react to
light.
7. Shine a light
obliquely through
 anterior chamber
from lateral side
toward nasal side.
Inspection Test for papillary response to
light and reaction to
accommodation in dimly lit
room.
22. Instruct client to look
straight ahead.
23. Bring penlight from
side of the client’s face to
directly in front of the
pupil.
24. Note quickness or
response to light.
25. Shine light into same
eye observing for response
or pupil for equality of
size and repeat steps to the
other eye.
26. 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.
27. Move finger toward
the bridge of client’s nose
noting response of both
pupil.
28. Record results
Pupils should constrict The patient's pupils The patient's pupils
quickly in direct rapidly contract in exhibit a prompt and
response to light and the direct reaction to light, simultaneous
opposite pupil should and the corresponding constriction in response
also constrict. pupil on the opposite to direct exposure to
side also constrict. light. This coordinated
Pupil should be equal in
reaction indicates a
size. The size of the patient's
healthy and
pupil is equal.
Papillary synchronized pupillary
accommodation causes response, indicative of
constriction in response normal neurological
to objects that are near. function and visual
pathways.
Pupillary dilatation
occurs when pupils
accommodate objects at
a distance, with
symmetrical
convergence of eyes.
 PERRLA (pupils equal,
round, reactive to light
accommodation).

8. EARS
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
External ear Inspection Examine external ear, called Symmetrical, with upper The patient's ears are of Upon inspection the
the auricle or pinna for attachment at eye corner equal size, the auricle patient's ears
placement, symmetry, color, level, and is fleshed aligns with the corner demonstrate
discharge and swelling. colored. of the eye, and the symmetrical
color of her ears proportions, with the
matches her skin tone. auricle aligning
appropriately with the
corner of the eye with
no signs of any
abnormalities.
Palpation Palpate the auricle between Firm, smooth, free from The auricle and pinna There are no signs of
the thumb and index finger lesions and pain. of the patient is abnormalities.
noting lesions or tenderness smooth, firm and free
by moving auricle up and from any lesions or
down, same with the mastoid swelling.
tip.
Press inward on tragus noting
any tenderness.
Auditory acuity Inspection The Whispered Voice Test The client should be The patient’s hearing is There are no signs of
able to repeat whispered excellent and can
 13. Instruct the client to words. repeat whispered abnormalities.
occlude one ear with words.
finger and repeat the
words when heard.
14. Stand 1-2 feet away
from the client, out of
view to avoid client
from lip reading, and
softly whisper
numbers on side of the
ears. Increase voice
volume until client
identifies uttered
number.
15. Repeat procedure on
other ear.
16. Record results.

9. NOSE AND SINUSES

AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION

Nose Inspection Inspect the nose for
symmetry, deformity, flaring,
or inflammation and
discharge from the nares.
Test patency of each nostril:
g. Instruct client to close
the mouth and apply
Located symmetrically, The patient’s nose is The patient's nose is
midline of the face, and symmetrical, located in symmetrical alignment,
is without swelling, the midline of the face, positioned centrally on
bleeding, lesions, or and free from any the face. Furthermore, it
masses. lesions, swelling, or is observed to be free
bleeding. from any lesions,
swelling, or signs of
The patient’s nostril is
bleeding. This indicates
 pressure on one nares
and breathe
h. Repeat test on
opposite nares.
Nasal cavities Inspection Inspect the nasal cavity with a
penlight:
j. Tilt client’s head in an
extended position.
k. Place non dominant
hand on client’s head
using your thumb, and
lift the tip of the nose.
l. 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.
Each nostril is patent. patent. a normal and healthy
nasal condition.
Mucosa is pink or dull The patient’s septum is There are no signs of
without swelling or in the midline and abnormalities.
polyps. intact, mucosa is pink
and there are no signs
Septum is midline and
of any bleeding or
intact.
swelling.
A small amount of clear
watery discharge is
normal.
None-tender air filled Upon palpation, the There are no signs of
cavities. nasal sinuses are free abnormalities.
from sensitivity or
discomfort when
touched or palpated.
Resonant sound upon There is resonant sound
percussion. upon percussion.
 10. Mouth
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Breath Inspection Stand 12-18 inches in front of Breath should smell The patient's breath has Due to poor oral
client and smell the breath. fresh. a slight odor. hygiene.
The patient's lips are The lips appear dry,
brown in color, dry, and which indicates changes
Observe lips for color,
Lips free from any lesion. in hormonal levels.
moisture, swelling, lesions
g. Instruct client to open
mouth and use tongue
depressor to retract Lips and mucosa should
buccal mucosa and be pink, firm, and moist
note color, hydration, without inflammation or
inflammation, or
lesions.
lesions.
h. 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 Gums are pink, smooth The patient's gums are There are no signs of
and note color, edema, and moist. pink, moist and firm. abnormalities.
retraction, bleeding and
lesions.
 Palpation Palpate gums with tongue
blade for texture
Ask client to clench teeth to
assess position and alignment
Teeth Inspection
with the use of a tongue
depressor, expose molars and
note for tartar, cavities,
extraction and color.
Inspection Instruct client to protrude
tongue:
10. Inspect dorsum of
tongue and note for
color, hydration,
texture, symmetry.
Tongue 11. With penlight, inspect
sides and ventral
surface and note for
size, texture, nodules,
or ulcerations.
12. Still with penlight,
inspect floor of mouth,
salivary glands, and
Palpation duct openings.
Grasp tongue with a gauze
and gently pull it to one side
and palpate full length of
tongue.
Gums are firm.
Teeth are properly The patient's teeth are Upon inspection it
aligned, smooth, white not properly aligned, indicates dental
and shiny. with a slightly irregularities and
yellowish color. potential issues with oral
hygiene.
When protruded, tongue The patient's tongue is The dorsal surface of the
lays midline, medium in midline, with the tongue appears smooth
red or pink in color, dorsal surface smooth and devoid of any
and free of lesion.
moist and smooth along lesions or abnormalities.
lateral margins, with
free mobility. The patient's tongue
color is pink and is
The dorsal surface is smooth and moist in
slightly rough (taste texture.
buds) and free from
lesions.
The ventral surface is
highly vascular, smooth,
moist, and free of
lesions.
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Palate Inspection Inspect the soft and hard Palates are concave and The patient's palates are There are no signs of
palate with a penlight: pink. concave and the soft abnormalities.
palate is smooth with a
g. Instruct client to Hard palate has ridges.
light pink coloration.
extend head backward
and hold mouth open. Soft Palate is smooth.
The patient's hard
h. Inspect the hard palate palate has ridges and is
(roof of mouth) and firm in texture.
soft palate for color,
shape, lesions.
Inspection Inspect pharynx using tongue With phonation, the soft The patient's pharynx Upon inspection it is
depressor and penlight: palate and uvula rise and tonsil are pink in noted that the patient's
symmetrically. color and free from any pharynx and tonsils
p. Explain procedure to
Pharynx lesions. exhibit a normal and
client. The pharynx is pink,
q. Instruct client to tilt healthy appearance. The
vascular, lesion free.
head back and open coloration is described
mouth. Tonsil size is evaluated as pink, which is
r. With non-dominant using the grading scale. indicative of the typical
hand, place tongue hue of these structures.
depressor on middle
third of tongue. With
the dominant hand,
shine light into back of
throat.
s. Instruct client to say
“ah” and note position,
size, appearance of
tonsils and uvula.
t. Inform client of
 eliciting gag reflex by
touching the posterior
1/3 of tongue with
tongue blade if palate
and uvula fail to rise
symmetrically with
phonation.

11. NECK
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Inspection Instruct client to: Muscles are The patient's muscles We observed that the
symmetrical with head exhibit symmetry, and patient's neck
Symmetry and g. Flex chin to chest and
in central position. the head is centrally demonstrates
Musculature to teach side and
shoulder to test positioned. unrestricted movement,
Movement though full
anterior and there are no
range of motion without The patient's neck
sternocleidomastiod reported complaints of
complaint of discomfort movement can move
muscle. discomfort.
or limitation. freely without any
h. Hyperextend the neck
complaints of
backward to test
discomfort.
posterior trapezia.

Palpation Palpate lymph nodes and Lymph nodes should not The patient’s lymph There are no signs of
instruct client to relax and be palpable. Small, nodes are not palpable. abnormalities.
flex neck slightly forward. movable nodes are
insignificant.
10. Stand in front of
seated client.
11. Methodically palpate
Lymph nodes 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.
12. Note size, shape,
mobility, consistency
and tenderness.
Trachea Inspection Note for position. Midline position above The patient’s trachea is We observed that the
the suprasternal notch. located in a midline patient's trachea is
position above the appropriately situated in
Palpation Place thumbs and index finger suprasternal notch. And the midline position
on sides of trachea and apply there is no pain upon above the suprasternal
gentle pressure and palpate. palpation. notch. And there is no
reported pain upon
palpation, indicating that
the trachea is not tender
or sensitive to touch.
Palpation With client seated, assessment Thyroid cannot be The patient's thyroid is There are no signs of
may be done with posterior visualized. non tender and has a abnormalities.
and anterior approach: soft texture when
touched.
G. POSTERIOR
APPROACH It may or may not be
Thyroid
1. Stand behind client felt.
and place thumbs No bruits on
on nape of neck and
 bring fingers If felt, it should be auscultation.
interiorly around smooth, soft, non-tender
neck with their tips and not enlarged.
resting over tracheal
rings.
2. Ask client to tilt
chin forward to
relax neck muscles
and swallow.
3. Palpate the isthmus
rise under fingers
and feel each lateral
lobe before and
while client
swallow.
Auscultation 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
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.
H. 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/FEATURE TECHNIQUE SKILLS
TO ASSESS
Inspection Place client in sitting position
with arms folded across chest,
back exposed.
7. Assess shape and
symmetry by taking note
of the rate and rhythm of
Shape, symmetry, respirations, movement of
and diameter chest wall with deep
inspiration and full
expiration.
8. Estimate anteroposterior
diameter in proportion to
lateral diameter.
Lesions Palpation 13. Palpate for lesions or
areas of pain.
14. Palpate thoracic
expansion at 10th rib by
placing thumb close to
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Respirations are quite, The respiration rate is We observed that the
effortless, and regular, 17 breaths per minute. respiration rate of 17
with 12-20 breaths per The thorax moves breaths per minute
minute. smoothly and quietly indicates a normal and
during inhalation and steady breathing pattern.
Thorax rises and falls in
exhalation. No The smooth and quiet
unison with respiratory
deformities are movement of the thorax
cycle.
detected upon during both inhalation
Ribs slope across and palpation. and exhalation indicates
down, without proper respiratory
movement or bulging in function. The absence of
the intercostals spaces. any deformities upon
palpation indicates a
structurally sound chest
without noticeable
irregularities.
Thumb should separate Upon palpation, there The findings indicates
an equal distance of 3- are no lesions or that there are no
5cm and in the same tenderness detected on noticeable
direction during thoracic the posterior thorax. abnormalities, skin
expansion and meet in irregularities, or areas of
 client’s spine and spread
hands over thorax. Note
divergence of thumbs;
feel for range and
symmetry of movement
during deep inhalation
and full exhalation.
15. Place ulnar aspect of open
hand at right apex of lung
and place hand at each
posterior thorax location.
Then instruct client to say
“99” and palpate for
tactile fremitus
(vibrations caused by
vibrations). Note areas of
increased and decreased
fremitus.
16. 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.
7. Start at lung apices by
moving hands from side
to side across the top of
Sound Percussion each shoulder. Note sound
produced from each
percussion strike and
the midline on The symmetry of discomfort on the back
expiration. movement is evident of the thoracic region.
while palpating the
thoracis expansion.
Posterior thorax is free We observed that the
Fremitus is symmetric
from tenderness, lesions symmetry of movement
and easily identified in
and pulsations. during palpation of the
the upper region of the
thoracic expansion
lungs. It is equal on
indicates a balanced and
both sides of the
Fremitus is equal on uniform expansion of
thorax.
both sides of thorax, the chest.
strongest at the level of
We also observed that
tracheal bifurcation.
the fremitus, are evenly
distributed and readily
noticeable in the upper
portion of the lungs. The
symmetry in fremitus
implies a balanced and
uniform transmission of
vibrations during
palpation, particularly in
the upper respiratory
regions.
Air filled lungs create a Upon percussion, The presence of
resonant sound. resonant sound is resonant sounds during
heard. percussion on the thorax
and lung assessment is a
positive indication.
Resonance is a normal
 compare with and expected sound,
contralateral sound. suggesting that the
8. Continue downward and Identify contralateral
underlying lung tissue is
post lateral every other sound; bones create flat
air-filled and healthy.
intercostals space. Note sound. Thorax is more
intensity, pitch, duration, resonant in children and
and quality of percussion. thin adults.
Breath sounds Auscultation 13. Place diaphragm of Posterior sound: No adventitious Upon auscultation, there
stethoscope on right lung vesicular and sounds, such as is no abnormal sounds,
apex. Instruct client to bronchovesicular. crackles or wheezes are such as crackles or
inhale and exhale deeply auscultated. wheezes, were detected.
and slowly when
stethoscope is felt on the
Lateral sound: vesicular
back. Repeat on left lung
apex.
14. More downward every
other intercostals spaces A large chest will
and auscultate, placing produce decreased
stethoscope in the same breath sound.
position on both sides.
15. 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.
16. Repeat last step on the left
 side.
B. ANTERIOR THORAX
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
Inspection Place client in sitting position
or supine position. Inspect
client’s chest for:
Symmetry, rhythm
7. Symmetry and depth
and slope
of movement.
8. Slope of ribs and
musculoskeletal
deformities.
Tenderness, Palpation 10. Place fingerpads on Same normal findings
pulsation, masses right apex above the with posterior palpation.
and crepitance clavicle. Proceed
downward to each rib
and intercostals space
and note for
tenderness, pulsation,
masses and crepitance.
Repeat on left side.
Respiratory 11. Assess respiratory
excursion excursion by placing
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Thorax rises and falls in The respiration rate is We observed that the
unison with respiratory 17 breaths per minute. respiration rate of 17
cycle, ribs at 45 degrees The thorax moves breaths per minute
angle with sternum. smoothly and quietly indicates a normal and
Inspiratory breath during inhalation and steady breathing
sounds are not audible at exhalation. pattern. The smooth
a distance of more than and quiet movement of
2to 3 cm from mouth. the anterior thorax
during both inhalation
and exhalation
indicates proper
respiratory function.
There is no presence of The findings indicates
tenderness or pain that there are no
palpated over the area. noticeable
abnormalities, skin
irregularities, or areas
of discomfort on the
back of the thoracic
region.
 thumbs along each Fremitus is symmetric Fremitus is symmetric
costal margin with and easily identified. It and easily identified
hands on lateral rib is equal on both sides. which is normal.
cage. Instruct client to
inhale deeply; note for
divergence of thumbs
on expansion; feel
range and symmetry
Tactile Fremitus of respiratory
movement.
12. Palpate for tactile
fremitus. Gently
displace female
breasts as necessary.
Percussion Percuss anterior surface by: Resonant sound over Percussion elicits Upon percussion and
lung tissue dullness over breast auscultation, the
4. Percuss 2-3 strikes
(hyperresonance in tissue, the heart, and the symmetry and sound
along right lung apex
and repeat on left lung children and thin adults) liver. are found normal.
apex. Proceed Cardiac, liver, and
downward, percussing gastric silhouettes emit
in every ICS going dull sound.
from right to left in
same positions on both Ribs emit flat sound.
sides.

Symmetry and
sound Assess each thorax area:
13. Resonant lung filled.
14. Cardiac dullness: 3rd-
5th ICS left of sternum.
15. Liver dullness: place
 finger parallel to upper
border of expected
liver dullness in right
midclavicular line;
percuss downward.
16. Gastric air bubble:
repeat procedure done
on liver dullness on
the left side.

Auscultate anterior surface by

Auscultation instructing client to breath Tympany is detected There are no signs of
through the mouth and over the stomach, and abnormalities.
Anterior sounds:
compares symmetrical areas flatness is detected over
bronchial,
of lungs from above the bony prominence.
bronchovesicular,
downward:
vesicular.
10. Listen to breath
A large chest will
sounds and note
produce decreased
intensity and identify
variations from breath sounds.
normal.
11. Identify any added
sounds by location on
chest wall and time in
the respiratory cycle.
12. If breath sounds are
diminished, ask client
to breath hard and fast
with mouth open.
 13. CARDIOVASCULAR
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
Arterial Pulses Palpation Compress the radial artery
with your index finger and
middle finger.
Heart Inspection Precordial Movement
1. Position the patient supine
with the head slightly elevated
2. Always examine from the
Palpation patient's right side.
3. Palpate for point of
maximal impulse. (Normally
located at 4th or fifth ics,
1mcl)
Auscultation 4. Listen with diaphragm at
the right 2nd ICS
5. Listen to the 2nd ICS near
the sternum.
6. 3rd, 4th, 5th ICS near
sternum
7. Listen for apex
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Normal Heart rate Upon palpation, the Pulse rate of 95bpm
patient’s pulse rate is 95 falls within a moderate
beats per minute. range and is generally
considered within the
normal adult heart rate
range.
When the patient was Upon inspection, the There are no signs of
auscultated, the chest appears abnormalities.
pulsation in the mitral symmetrical without
area can be palpable and visible abnormalities or
when no signs of deformities.
irregular rhythm and
murmur sounds.
Upon palpation, the
pulse is regular and
strong, and the point of
maximal impulse is
palpable at the apex,
usually at the fifth
intercostal space in the
midclavicular line.
Upon auscultation, heart
sounds are clear and
well-defined.
Tissue perfusion Palpation Perform the Allen Test to Palms should turn pink The palm and fingers There are no signs of
determine patency of radial promptly. quickly regain their abnormalities.
and ulnar arteries. Instruct normal color, indicating
client to rest hands on lap. good blood flow through
1. Compress both the radial the released artery.
and ulnar arteries.
2. Firmly compress arteries
and instruct clients to open
their hands.
3. Note the color of the palms.
4. Release one artery and note
the color of the palm.
5. Repeat steps on other
arteries on the same hand.

14. ABDOMEN
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Generalized Inspection Placing client in supine Contour is flat or The patient’s abdomen, The presence of striae
appearance of position with knees flexed rounded and bilaterally there is small visible indicates the stretching
abdomen over a pillow, hands at side or symmetrical. bump and there are of the skin over time.
over the chest, undrape striae detected due to
patient from xiphoid process pregnancy.
to symphysis pubis to expose Umbilicus is depressed There are no signs of
abdomen. and beneath the abnormalities on the
abdominal surface. The patient’s abdomen, abdomen of the client.
13. Inspect abdomen
from rib margin to there is noticeable
pubic bone and note curvature upon
 for contour and Visible peristalsis is inspection.
symmetry. slowly transverses the
14. Inspect umbilicus abdomen in slanting
for contour, location, downward movements
signs of as observed in thin
inflammation or client. Pulsations of the
hernia.
abdominal aorta are
15. Observe for smooth,
visible in the epigastric
even respiratory
movements. area in thin clients.
16. Observe for surface
motions (visible
peristalsis)
Bowel sounds Auscultation Auscultate the bowel sounds High pitched sounds Bowel sounds are The presence of audible
on the abdominal quadrants heard every 5 to 15 audible in various bowel sounds in
using the diaphragm of the seconds as intermittent abdominal quadrants, as various abdominal
stethoscope. gurgling sounds in all 4 they represent the quadrants indicates
quadrants as a result of movement of contents normal gastrointestinal
10. Begin by placing the
fluid and air movement through the stomach. motility.
diaphragm on the
RLQ. Listen for a in GIT.
full minute to the
frequency and
character of bowel
movements.
11. Repeat same step
proceeding in Bowel sounds should
sequence to RUQ, always be heard at the
LUQ, and LLQ. ileocecal valve.
12. 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.
Tympany is heard Not be able to percuss.
because of air in the
stomach and intestines.
Dullness is heard over
organs.

15. NEUROLOGIC SYSTEM

ASSESSMENT OF COMMON DEEP TENDON REFLEX
TYPE ASSESSMENT NORMAL REFLEX KEY FINDINGS ANALYSIS AND
INTERPRETATION
10. Flex client’s arm No difficulties detected. The bicep reflex is
between 45 degree normal.
Biceps angle and 90 degree. There should be flexion of arm
11. Place thumb firmly on at elbow.
biceps tendon just
above the crease of
antecubital fossa.
12. Tap thumb with reflex
hammer.
Triceps 7. Flex client’s arm at 45 Extension of elbow When the triceps tendon is The contraction of the
degree and 90 degree tapped, the forearm extends triceps muscle is normal.
angle. at the elbow joint.
8. Tap triceps tendon just
above the elbow.
7. Flex client’s arm at 45 Flexion of forearm Forearm flexion is present. Normal forearm flexion.
 Brachioradialis degree angle and place
on lap with the arm
semipronated.
8. Tap brachioradialis
tendon on thumb side
of the wrist.
7. Ask the client to sit in a Extension of leg below the The quadriceps muscle Normal leg extension and
chair or on edge of bed knee. contracts as the knee quadriceps muscle
Patellar with legs hanging stretches. contraction.
freely or in supine
position with knee
flexed.
8. Tap patellar tendon just
below the patella.
7. Ask client to sit with Plantar flexion of foot. Plantar flexion is present. The plantar flexion of the
feet dangling and foot is normal.
Achilles partially dorsiflexed or
in a supine position
with legs flexed at knee
and thigh externally
rotated.
8. Tap the Achilles tendon
just above the heel.
7. Position client’s ankle Bending of the toes downward. There is the presence of toe- The response is normal.
firmly against the bed. curling.
Plantar (Babinski) 8. Slowly stroke client’s
sole with the handle of
the reflex hammer.
 Name: Ms. N
1. SKIN
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color Inspection Inspect variations in skin Color varies from light Her skin color is light There are no signs of
color under natural sunlight to to ruddy pink or dark brown. abnormalities.
ensure accuracy findings. brown, depending on the
race. Color is uniform
except for sun exposed
areas or normally
lighted pigmented areas
(nailbeds, palms, lips) in
dark skinned people.
Lesions Inspection Note for color, size, and Freckles, skin tags in She has stretch mark or Striae are present due to
anatomic location and elderly, and some types striae due to her weight her weight gain.
distribution. of birthmarks and moles gain.
are normal.
 Palpation Palpate lesions with finger Moles are present in
pads for mobility and contour the patient arms, chest.
(flat, raised, or depressed) and and on her feet
consistency (soft or durable)
Moisture Inspection Note amount and distribution Moisture varies with Her skin is soft and The her skin is oily due
and Palpation activity, body and oily. to naturally high
environmental moisture.
temperature, and
humidity in skin folds
and the axillae.
Temperature Palpation Palpate with dorsum of hand Temperature should be Her Temperature is The patient temperature
noting for uniformity of uniform and within 36.6°and her body is is warm to touch, due to
warmth. normal range. warm. the humid weather.
Texture (quality, Palpation Palpate with finger pads in Texture is not uniform Her palms are soft, and There are no signs of
thickness, different areas like the palms and soles the soles, also there are abnormalities.
suppleness) are thicker than any no presence of lesions.
areas. Wrinkled and
leathery skin in the
elderly results from the
normal aging. Process
with decreased collagen,
subcutaneous fats, and
sweat glands.

AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND

TO ASSESS INTERPRETATION
Mobility and turgor Palpation Assess mobility and turgor to Absence of indention is After pinching the There are no signs of
(elasticity) measure elasticity of skin to dependent areas and the client's skin, it quickly abnormalities.
determine the degree of resilience of the skin turns back to its
hydration. spring back to its original position in less
previous state after than 1 secs.
being pinched.
There are no signs of
Palpate dependent areas like
edema.
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:
21. 0 = no pitting
22. 1+ = trace/mild
(2mm) pitting
23. 2+ = moderate
(4mm) pitting
24. 3+ = deep/severe
(6mm)
25. 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/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color and Inspect Assess for color and Color varies from black Her hair is evenly She has a chemical
Distribution distribution of scalp hair, to pale blonde based on distributed, and her hair colored hair.
eyebrows, eyelashes, and the amount of melanin is chemically color
body surface. present. brown.
Texture and oiliness Palpation Assess for the skin’s texture Thin, straight, coarse, Her hair is thin, oily Excessive application of
and oiliness with the use of thick, or curly. Hair is and frizzy. chemical hair color can
palm. shiny and resilient lead to frizzy hair.
infestation Inspection Assess for any presence of Free from any There are no presence There are no signs of
infestation by examining the infestation. lice or infestation. abnormalities.
hair and scalp.

3. SCALP
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Scaliness and scars Inspection Part the hair repeatedly all The scalp should be Her scalp is clean and There are no signs of
 over the scalp and inspect for
scaliness and scars.
Tenderness, lesions, Palpation Place finger pads on the scalp
lumps, masses at the front and palpate down
the midline and each side for
tenderness, lesions, lumps, or
masses.
shiny and smooth smooth, also there is no abnormalities.
without lesions, lumps, signs of any lesions or
or masses. masses.
Absence of redness or There is no tenderness, There are no signs of
scaliness. lesions, lumps, or abnormalities.
masses on the patient’s
scalp.

4. NAILS
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color, shape, and Inspection Inspect for color and shape Nailbeds is highly Her nail bed is light There are no signs of
texture vascular with a pink pink and the shape of abnormalities.
color in light skinned the nail is round.
clients and longitudinal
streaks of brown or
black pigmentation in
dark skinned clients.
Angle between
fingernail and base is Upon palpation, her
about 160 degrees. nails are smooth and
firm.
Palpation Palpate nailbed for firmness
 and texture
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.
Nailbed is firm
When pressure is Upon the release of There are no signs of
released from the nail, it pressure from the nail, abnormalities.
promptly returns to its it quickly returns to its
normal color. usual color in less than
1 second.
Tissue surrounding the The tissue surrounding There are no signs of
nail is intact. the nail remains intact abnormalities.
and free from any
lesions.

5. SKULL
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Shape and symmetry Inspection Inspect skull for shape, Rounded, symmetrical, Her skull is round and Upon examining and
symmetry, size in proportion normocephalic, and symmetrical. understanding the her
to body and position. upright. skull indicates well-
proportioned and
symmetrical structure.
 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.
6. FACE
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
Facial features Inspection Inspect facial features for
expression, shape, and
symmetry of eyebrows,
placement of nose, eyes, and
ears.
Edema and masses Inspection Inspect for any presence of
edema and masses
7. EYES
Smooth, non-tender, free Her skull is smooth and There are no signs of
of masses or there’s no any signs of abnormalities.
depressions. masses, depressions or
tenderness palpated.
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
May be oval, round, or Her face is round and There are no signs of
square. Symmetrical symmetrical in shape, abnormalities.
features and movement. with symmetrical
features such as
eyebrows, nose, eyes,
and ears.
No edema and masses There is no presence of There are no signs of
edema or masses on the abnormalities.
patient’s face.
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION

Visual Acuity Inspection Test visual acuity. Normal vision based on Her visual acuity is in There’s no any signs of
the Snellen chart is 20/20 normal 20/20 vision abnormalities on her
29. Position Snellen chart 20
at the distance of 20 feet She hasn’t experienced visual acuity.
ft. in front of client.
30. Remove corrective the normal eye can read a blurry vision.
lenses, if appropriate. the chart).
31. Instruct client to cover
one eye and read lines
starting with top of chart
from left to right.
32. Note the line where client
reads more than half of
the letters.
33. Record results as a
fraction sc (without
correction), 20/ distance
number, and the number
of the letters missed.
34. Repeat same steps for the
other eye.
35. If appropriate, repeat
steps with patient
wearing the corrective
device.
Inspection Test eye for extraocular Eye movement should The smooth eyes There are no signs of
muscle movements: be symmetrical as both movement is evident, abnormalities.
eyes follow the direction with both eyes
33. Place the client in sitting
of the gaze and smoothly following the
position.
34. Instruct the client to hold converge on the held gaze direction and
 head still. object as its moves converging on the
35. Ask the client to follow toward the nose. object as it moves
an object with eyes. closer to the nose.
36. Move objects with 6
fields of gaze.
***The 6 Fields of Gaze The upper eyelids cover Her upper eyelids cover Upon examination, her
only the uppermost part only her uppermost upper eyelid is stable
25. Conjugate left lateral
of the iris and are free parts of the iris and has without any abnormal
gaze
26. Left down and lateral from nystagmus no signs of nystagmus, twitching or oscillations.
gaze (involuntary rhythmical indicating a lack of
27. Right down and lateral oscillation of the eyes). involuntary and
gaze A few beats of rhythmic movements in
28. Conjugate right lateral nystagmus with extreme the eyes.
gaze lateral gaze can be
29. Right up and lateral gaze normal.
30. Left up and lateral
37. Observe for parallel eye
movement.
38. Pause during upward and
lateral gaze field to detect
in voluntary rhythmic
oscillation of eyes.
39. Note position of upper
eyelid in relation to the
iris and eyelid bag as the
client’s eye move from
up and down.
40. Move object forward to
about 5 inches in front of
the client’s nose at the
midline and observe for
 convergence, and record
result.
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
External anatomical Inspection Observe upper eyelid.
structures
Check eyes and eyelids for
inflammation, crusting, edema Eyes and eyelids should
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.
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Upper eyelid should Her upper eyelid There are no signs of
overlap iris. margin overlaps the abnormalities.
iris.
be free from There is no presence of
inflammation, crusting, inflammation, edema,
edema or masses. or masses on her eye
and eyelids.
Her lacrimal glands
indicate no redness or
swelling.
Lacrimal gland should Her lacrimal gland is There are no signs of
not be palpable. not palpated, and the abnormalities.
tears flow easily from
the lacrimal gland to
Tears flow freely from the lacrimal duct
the lacrimal gland over through the cornea and
the cornea and conjunctiva.
conjunctiva to the
lacrimal duct.
Bulbar is transparent Her bulbar is clear and There are no signs of
with small blood with the presence of abnormalities.
vessels. small blood vessels.
m. Instruct client to look Palpebral conjunctiva Her palpebral
upward while depressing covering the inside of conjunctiva is moist
lower lid with thumb. the upper and lower and free from any
n. Inspect for color, redness, eyelids is pink and swelling.
swelling, exudates, or moist.
foreign bodies. Her Sclera is white, and
o. Inspect cornea, lenses, Sclera is white with her cornea is
pupil, iris, and anterior some superficial blood transparent, moist and
chamber: vessels depending on the clear.
1. Stand in front of race.
the client.
2. Shine penlight
directly on cornea.
Corneas are moist, shiny
3. Move light
laterally and view and clear.
cornea from that Lenses are transparent.
angle; note color,
discharge, and Pupils are black, round
lesions. and equal diameter,
4. Look at pupil and ranging from 2-6mm.
note size and
shape. Entire iris should
5. Shine penlight illuminate when shining
directly on pupils light laterally too
to assess lens and nasally.
color.
6. Look at iris for
size, and ability of
pupils to react to
light.
7. Shine a light
obliquely through
 anterior chamber
from lateral side
toward nasal side.
Inspection Test for papillary response to Pupils should constrict Her pupils constrict the Her pupils simultaneous
light and reaction to quickly in direct direct reaction to light, constriction in response
accommodation in dimly lit response to light and the and the corresponding to direct exposure to
room. opposite pupil should pupil on the opposite light. This coordinated
also constrict. side also constrict. reaction suggests a
29. Instruct client to look
healthy and
straight ahead. Pupil should be equal in The size of her pupil is
30. Bring penlight from synchronized pupillary
size. equal.
side of the client’s face to response, indicative of
directly in front of the Papillary normal neurological
pupil. accommodation causes function and visual
31. Note quickness or constriction in response pathways.
response to light. to objects that are near.
32. Shine light into same
eye observing for response Pupillary dilatation
or pupil for equality of occurs when pupils
size and repeat steps to the accommodate objects at
other eye. a distance, with
33. Instruct client to gaze symmetrical
at your finger held 4-6 convergence of eyes.
inches from her nose then
to glance at a distant
object while you note
papillary reflex.
34. Move finger toward
the bridge of client’s nose
noting response of both
pupil.
35. Record results
 PERRLA (pupils equal,
round, reactive to light
accommodation).

8. EARS
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
External ear Inspection Examine external ear, called Symmetrical, with upper Her ears are of equal Upon inspection , we
the auricle or pinna for attachment at eye corner in size, the auricle is observed that her ears
placement, symmetry, color, level, and is fleshed properly aligns with the demonstrate a
discharge and swelling. colored. corner of the eye, and symmetrical
the color of her ears proportions, with the
matches her skin tone. auricle aligning
appropriately with the
corner of the eye with
no signs of any
abnormalities.
Palpation Palpate the auricle between Firm, smooth, free from The auricle and pinna There are no signs of
the thumb and index finger lesions and pain. of the patient is abnormalities.
noting lesions or tenderness smooth, firm and free
by moving auricle up and from any lesions or
down, same with the mastoid swelling.
tip.
Press inward on tragus noting
any tenderness.
Auditory acuity Inspection The Whispered Voice Test The client should be Her hearing is clear There are no signs of
able to repeat whispered and can repeat the
 17. Instruct the client to words. whispered words. abnormalities.
occlude one ear with
finger and repeat the
words when heard.
18. Stand 1-2 feet away
from the client, out of
view to avoid client
from lip reading, and
softly whisper
numbers on side of the
ears. Increase voice
volume until client
identifies uttered
number.
19. Repeat procedure on
other ear.
20. Record results.

9. NOSE AND SINUSES

AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION

Nose Inspection Inspect the nose for
symmetry, deformity, flaring,
or inflammation and
discharge from the nares.
Test patency of each nostril:
i. Instruct client to close
the mouth and apply
Located symmetrically, Her nose is We observed that she is
midline of the face, and symmetrical, located in free from any lesions,
is without swelling, the proper position in swelling, or signs of
bleeding, lesions, or the face, and there are bleeding. And This
masses. no signs any lesions, indicates a normal nasal
swelling, or each of her condition.
nostril is patent
 pressure on one nares Each nostril is patent.
and breathe
j. Repeat test on
opposite nares.
Nasal cavities Inspection Inspect the nasal cavity with a Mucosa is pink or dull Her septum is in the There are no signs of
penlight: without swelling or midline and intact, abnormalities.
polyps. mucosa is pink and
m. Tilt client’s head in an
there are no signs of
extended position. Septum is midline and
n. Place non dominant any bleeding or
intact.
hand on client’s head swelling.
using your thumb, and A small amount of clear
lift the tip of the nose. watery discharge is
o. With the lit penlight, normal.
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 None-tender air filled Her nasal sinuses are There are no signs of
on frontal and maxillary areas cavities. free from sensitivity or abnormalities.
avoiding pressure on the eyes. discomfort when it is
touched or palpated.
Percuss area and note the
sound. We heard that there is
Resonant sound upon resonant sound upon
percussion. percussion.
 10. Mouth
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Breath Inspection Stand 12-18 inches in front of Breath should smell Her breath is fresh. Through good hygiene
client and smell the breath. fresh. her breath becomes
fresh.
Her lips are pink in
Observe lips for color, color and free from any
Lips
moisture, swelling, lesions lesion. There are no visible
lesions or abnormalities
i. Instruct client to open
present.
mouth and use tongue
depressor to retract Lips and mucosa should
buccal mucosa and be pink, firm, and moist
note color, hydration, without inflammation or
inflammation, or
lesions.
lesions.
j. 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 Gums are pink, smooth Her gums are pink, There are no signs of
and note color, edema, and moist. moist and firm. abnormalities.
retraction, bleeding and
lesions.
 Palpation Palpate gums with tongue
blade for texture
Ask client to clench teeth to
assess position and alignment
Teeth Inspection
with the use of a tongue
depressor, expose molars and
note for tartar, cavities,
extraction and color.
Inspection Instruct client to protrude
tongue:
13. Inspect dorsum of
tongue and note for
color, hydration,
texture, symmetry.
Tongue 14. With penlight, inspect
sides and ventral
surface and note for
size, texture, nodules,
or ulcerations.
15. Still with penlight,
inspect floor of mouth,
salivary glands, and
Palpation duct openings.
Grasp tongue with a gauze
and gently pull it to one side
and palpate full length of
tongue.
Gums are firm.
Teeth are properly The patient's teeth are There’s no signs of
aligned, smooth, white properly aligned, with a abnormalities present.
and shiny. whitish color, and there
are some spaces of
tooth on the left side.
When protruded, tongue Her tongue is in The dorsal surface of the
lays midline, medium midline, with the dorsal tongue appears smooth
red or pink in color, surface smooth and free and devoid of any
of lesion.
moist and smooth along lesions or abnormalities.
lateral margins, with
free mobility. Her tongue color is
pink and is smooth and
The dorsal surface is moist in texture.
slightly rough (taste
buds) and free from
lesions.
The ventral surface is
highly vascular, smooth,
moist, and free of
lesions.
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Palate Inspection Inspect the soft and hard Palates are concave and Her palates are concave There are no signs of
palate with a penlight: pink. and the soft palate is abnormalities.
smooth with a light
i. Instruct client to Hard palate has ridges.
pink coloration and her
extend head backward
and hold mouth open. Soft Palate is smooth. hard palate has ridges,
j. Inspect the hard palate it is firm in texture.
(roof of mouth) and
soft palate for color,
shape, lesions.
Inspection Inspect pharynx using tongue With phonation, the soft Her pharynx and tonsil Upon inspection it is
depressor and penlight: palate and uvula rise are pink in color and noted that the patient's
symmetrically. there are no signs of pharynx and tonsils
u. Explain procedure to
Pharynx any lesions. exhibit a normal and
client. The pharynx is pink,
v. Instruct client to tilt healthy appearance. The
vascular, lesion free.
head back and open coloration is described
mouth. Tonsil size is evaluated as pink, which is
w. With non-dominant using the grading scale. indicative of the typical
hand, place tongue hue of these structures.
depressor on middle
third of tongue. With
the dominant hand,
shine light into back of
throat.
x. Instruct client to say
“ah” and note position,
size, appearance of
tonsils and uvula.
y. Inform client of
 eliciting gag reflex by
touching the posterior
1/3 of tongue with
tongue blade if palate
and uvula fail to rise
symmetrically with
phonation.

11. NECK
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Inspection Instruct client to: Muscles are Her muscles exhibit We observed that her
symmetrical with head symmetry, and the head neck demonstrates
Symmetry and i. Flex chin to chest and
in central position. is centrally positioned. unrestricted movement,
Musculature to teach side and
shoulder to test and there are no
Movement though full Her neck movement
anterior reported complaints of
range of motion without can move freely
sternocleidomastiod discomfort.
complaint of discomfort without any complaints
muscle. or limitation. of discomfort.
j. Hyperextend the neck
backward to test
posterior trapezia.

Palpation Palpate lymph nodes and Lymph nodes should not The patient’s lymph There are no signs of
instruct client to relax and be palpable. Small, nodes are not palpable. abnormalities.
flex neck slightly forward. movable nodes are
insignificant.
13. Stand in front of
seated client.
14. Methodically palpate
Lymph nodes 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.
15. Note size, shape,
mobility, consistency
and tenderness.
Trachea Inspection Note for position. Midline position above The patient’s trachea is We observed that her
the suprasternal notch. located in a midline trachea is appropriately
position above the situated in the midline
Palpation Place thumbs and index finger suprasternal notch. And position above the
on sides of trachea and apply there is no pain upon suprasternal notch. And
gentle pressure and palpate. palpation. there is no reported pain
upon palpation,
indicating that the
trachea is not tender or
sensitive to touch.
Palpation With client seated, assessment Thyroid cannot be Her thyroid is non There are no signs of
may be done with posterior visualized. tender and has a soft abnormalities.
and anterior approach: texture when touched.
I. POSTERIOR
APPROACH It may or may not be
Thyroid
1. Stand behind client felt. No bruits on
and place thumbs auscultation.
on nape of neck and
 bring fingers If felt, it should be
interiorly around smooth, soft, non-tender
neck with their tips and not enlarged.
resting over tracheal
rings.
2. Ask client to tilt
chin forward to
relax neck muscles
and swallow.
3. Palpate the isthmus
rise under fingers
and feel each lateral
lobe before and
while client
swallow.
Auscultation 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
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.
J. 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/FEATURE TECHNIQUE SKILLS
TO ASSESS
Inspection Place client in sitting position
with arms folded across chest,
back exposed.
9. Assess shape and
symmetry by taking note
of the rate and rhythm of
Shape, symmetry, respirations, movement of
and diameter chest wall with deep
inspiration and full
expiration.
10. Estimate anteroposterior
diameter in proportion to
lateral diameter.
Lesions Palpation 17. Palpate for lesions or
areas of pain.
18. Palpate thoracic
expansion at 10th rib by
placing thumb close to
client’s spine and spread
hands over thorax. Note
divergence of thumbs;
feel for range and
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Respirations are quite, The respiration rate is There are no signs of
effortless, and regular, 17breaths per minute. any abnormalities upon
with 12-20 breaths per The thorax moves observing her
minute. smoothly and quietly respiratory rate.
during inhalation and
Thorax rises and falls in
exhalation. No
unison with respiratory
deformities are
cycle.
detected upon
Ribs slope across and palpation.
down, without
movement or bulging in
the intercostals spaces.
Thumb should separate Upon palpation, there The findings indicates
an equal distance of 3- are no lesions or that there are no
5cm and in the same tenderness detected on noticeable
direction during thoracic the posterior thorax. abnormalities, skin
expansion and meet in irregularities, or areas of
The symmetry of
the midline on discomfort on the back
movement is evident
expiration. of the thoracic region.
while palpating the
thoracis expansion.
 symmetry of movement
during deep inhalation
and full exhalation.
19. Place ulnar aspect of open
hand at right apex of lung
and place hand at each
posterior thorax location.
Then instruct client to say
“99” and palpate for
tactile fremitus
(vibrations caused by
vibrations). Note areas of
increased and decreased
fremitus.
20. 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.
9. Start at lung apices by
moving hands from side
to side across the top of
Sound Percussion each shoulder. Note sound
produced from each
percussion strike and
compare with
contralateral sound.
10. Continue downward and
post lateral every other
Posterior thorax is free Fremitus is symmetric We observed that the
from tenderness, lesions and easily identified in symmetry of movement
and pulsations. the upper region of the during palpation of the
lungs. It is equal on thoracic expansion
both sides of the indicates a balanced and
thorax. uniform expansion of
Fremitus is equal on
both sides of thorax, the chest.
strongest at the level of
We also observed that
tracheal bifurcation.
the fremitus, are evenly
distributed and readily
noticeable in the upper
portion of the lungs. The
symmetry in fremitus
implies a balanced and
uniform transmission of
vibrations during
palpation, particularly in
the upper respiratory
regions.
Air filled lungs create a Upon percussion, The presence of
resonant sound. resonant sound is resonant sounds during
heard. percussion on the thorax
and lung assessment is a
positive indication.
Resonance is a normal
and expected sound,
Identify contralateral suggesting that the
sound; bones create flat underlying lung tissue is
sound. Thorax is more
 intercostals space. Note resonant in children and air-filled and healthy.
intensity, pitch, duration, thin adults.
and quality of percussion.
Breath sounds Auscultation 17. Place diaphragm of Posterior sound: No adventitious Upon auscultation, there
stethoscope on right lung vesicular and sounds, such as is no abnormal sounds,
apex. Instruct client to bronchovesicular. crackles or wheezes are such as crackles or
inhale and exhale deeply auscultated. wheezes, were detected.
and slowly when
stethoscope is felt on the
Lateral sound: vesicular
back. Repeat on left lung
apex.
18. More downward every
other intercostals spaces A large chest will
and auscultate, placing produce decreased
stethoscope in the same breath sound.
position on both sides.
19. 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.
20. Repeat last step on the left
side.

B. ANTERIOR THORAX
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
 TO ASSESS
Inspection Place client in sitting position
or supine position. Inspect
client’s chest for:
Symmetry, rhythm
9. Symmetry and depth
and slope
of movement.
10. Slope of ribs and
musculoskeletal
deformities.
Tenderness, Palpation 13. Place fingerpads on Same normal findings
pulsation, masses right apex above the with posterior palpation.
and crepitance clavicle. Proceed
downward to each rib
and intercostals space
and note for
tenderness, pulsation,
masses and crepitance.
Repeat on left side.
Respiratory 14. Assess respiratory
excursion excursion by placing
thumbs along each
costal margin with
hands on lateral rib
cage. Instruct client to
inhale deeply; note for
INTERPRETATION
Thorax rises and falls in Her respiration rate is 16 We observed that the
unison with respiratory breaths per minute, respiration rate of 16
cycle, ribs at 45 degrees thorax moves smoothly breaths per minute
angle with sternum. and quietly during which indicates a
Inspiratory breath inhalation and normal and steady
sounds are not audible at exhalation. breathing pattern. The
a distance of more than smooth and quiet
2to 3 cm from mouth. movement of the
anterior thorax during
both inhalation and
exhalation indicates
proper respiratory
function.
There is no presence of The findings indicates
tenderness or pain that there are no
palpated over the area. noticeable
abnormalities, skin
irregularities, or areas
of discomfort on the
back of the thoracic
region.
Fremitus is symmetric Fremitus is symmetric
and easily identified. It and easily identified
is equal on both sides. which is normal.
 divergence of thumbs
on expansion; feel
range and symmetry
of respiratory
movement.
Tactile Fremitus 15. Palpate for tactile
fremitus. Gently
displace female
breasts as necessary.
Percussion Percuss anterior surface by: Resonant sound over Percussion elicits Upon percussion and
lung tissue dullness over breast auscultation, the
5. Percuss 2-3 strikes
(hyperresonance in tissue, the heart, and the symmetry and sound
along right lung apex
and repeat on left lung children and thin adults) liver. are found normal.
apex. Proceed Cardiac, liver, and
downward, percussing gastric silhouettes emit
in every ICS going dull sound.
from right to left in
same positions on both Ribs emit flat sound.
sides.

Symmetry and
sound Assess each thorax area:
17. Resonant lung filled.
18. Cardiac dullness: 3rd-
5th ICS left of sternum.
19. Liver dullness: place
finger parallel to upper
border of expected
liver dullness in right
midclavicular line;
percuss downward.
 20. Gastric air bubble:
repeat procedure done
on liver dullness on
the left side.

Auscultate anterior surface by

Auscultation instructing client to breath Tympany is detected There are no signs of
through the mouth and over the stomach, and abnormalities.
Anterior sounds:
compares symmetrical areas flatness is detected over
bronchial,
of lungs from above the bony prominence.
bronchovesicular,
downward:
vesicular.
13. Listen to breath
A large chest will
sounds and note
produce decreased
intensity and identify
variations from breath sounds.
normal.
14. Identify any added
sounds by location on
chest wall and time in
the respiratory cycle.
15. If breath sounds are
diminished, ask client
to breath hard and fast
with mouth open.

13. CARDIOVASCULAR
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Arterial Pulses Palpation Compress the radial artery
with your index finger and
middle finger.
Heart Inspection Precordial Movement
1. Position the patient supine
with the head slightly elevated
2. Always examine from the
Palpation patient's right side.
3. Palpate for point of
maximal impulse. (Normally
located at 4th or fifth ics,
1mcl)
Auscultation 4. Listen with diaphragm at
the right 2nd ICS
5. Listen to the 2nd ICS near
the sternum.
6. 3rd, 4th, 5th ICS near
sternum
7. Listen for apex
Tissue perfusion Palpation Perform the Allen Test to
determine patency of radial
and ulnar arteries. Instruct
client to rest hands on lap.
Normal Heart rate Upon palpation, the Pulse rate of 96bpm
patient’s pulse rate is 96 falls within a moderate
beats per minute. range and is generally
considered within the
normal adult heart rate
range.
When the patient was Upon inspection, the There are no signs of
auscultated, the chest appears abnormalities.
pulsation in the mitral symmetrical without
area can be palpable and visible abnormalities or
when no signs of deformities.
irregular rhythm and
murmur sounds.
Upon palpation, the
pulse is regular and
strong, and the point of
maximal impulse is
palpable at the apex,
usually at the fifth
intercostal space in the
midclavicular line.
Upon auscultation, heart
sounds are clear and
well-defined.
Palms should turn pink The palm and fingers There are no signs of
promptly. quickly regain their abnormalities.
normal color, indicating
good blood flow through
 1. Compress both the radial the released artery.
and ulnar arteries.
2. Firmly compress arteries
and instruct clients to open
their hands.
3. Note the color of the palms.
4. Release one artery and note
the color of the palm.
5. Repeat steps on other
arteries on the same hand.

14. ABDOMEN
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Generalized Inspection Placing client in supine Contour is flat or Her abdomen is evenly Her abdomen is evenly
appearance of position with knees flexed rounded and bilaterally round, bulky and there round and has
abdomen over a pillow, hands at side or symmetrical. are striae detected due to significant asymmetry
over the chest, undrape gain weight. or bulging. The
patient from xiphoid process presence of striae, often
Her umbilicus is in the
to symphysis pubis to expose Umbilicus is depressed associated with her
midline, and the skin
abdomen. and beneath the gaining weight.
color is same to the
abdominal surface.
17. Inspect abdomen surrounding abdominal
from rib margin to skin tone.
pubic bone and note There are no signs of
for contour and Visible peristalsis is Her abdomen is smooth abnormalities on the
symmetry. slowly transverses the and it is even respiratory abdomen of the client.
18. Inspect umbilicus abdomen in slanting movements.
for contour, location, downward movements
 signs of as observed in thin No abnormal
inflammation or client. Pulsations of the respiratory movements
hernia. abdominal aorta are are observed.
19. Observe for smooth, visible in the epigastric
even respiratory area in thin clients.
movements.
20. Observe for surface
motions (visible
peristalsis)
Bowel sounds Auscultation Auscultate the bowel sounds High pitched sounds Bowel sounds are The presence of audible
on the abdominal quadrants heard every 5 to 15 audible in various bowel sounds in
using the diaphragm of the seconds as intermittent abdominal quadrants, as various abdominal
stethoscope. gurgling sounds in all 4 they represent the quadrants indicates
quadrants as a result of movement of contents normal gastrointestinal
13. Begin by placing the
fluid and air movement through the stomach. motility.
diaphragm on the
RLQ. Listen for a in GIT.
full minute to the
frequency and
character of bowel
movements.
14. Repeat same step
proceeding in Bowel sounds should
sequence to RUQ, always be heard at the
LUQ, and LLQ. ileocecal valve.
15. Listen at least for 5
minutes before
concluding the
absence of bowel
sounds.
Abdominal Percussion Begin percussion in RLQ, Tympany is heard Tympanic sounds are Tympanic sounds over
quadrants move upward to RUQ, cross because of air in the over air-filled structures air-filled structures
 over to LUQ, and down to
LLQ. Note when tympani
changes to dullness.
stomach and intestines. like the stomach and such as the stomach
Dullness is heard over intestines and a hollow, and intestines indicates
organs. drum-like sound is normal findings during
produced upon abdominal percussion.
percussion.

15. NEUROLOGIC SYSTEM

ASSESSMENT OF COMMON DEEP TENDON REFLEX
TYPE ASSESSMENT NORMAL REFLEX KEY FINDINGS ANALYSIS AND
INTERPRETATION
13. Flex client’s arm No difficulties detected. The bicep reflex is
between 45 degree normal.
Biceps angle and 90 degree. There should be flexion of arm
14. Place thumb firmly on at elbow.
biceps tendon just
above the crease of
antecubital fossa.
15. Tap thumb with reflex
hammer.
Triceps 9. Flex client’s arm at 45 Extension of elbow When the triceps tendon is The contraction of the
degree and 90 degree tapped, the forearm extends triceps muscle is normal.
angle. at the elbow joint.
10. Tap triceps tendon just
above the elbow.
9. Flex client’s arm at 45 Flexion of forearm Forearm flexion is present. Normal forearm flexion.
degree angle and place
on lap with the arm
 Brachioradialis semipronated.
10. Tap brachioradialis
tendon on thumb side
of the wrist.
9. Ask the client to sit in a Extension of leg below the The quadriceps muscle Normal leg extension and
chair or on edge of bed knee. contracts as the knee quadriceps muscle
Patellar with legs hanging stretches. contraction.
freely or in supine
position with knee
flexed.
10. Tap patellar tendon just
below the patella.
9. Ask client to sit with Plantar flexion of foot. Plantar flexion is present. The plantar flexion of the
feet dangling and foot is normal.
Achilles partially dorsiflexed or
in a supine position
with legs flexed at knee
and thigh externally
rotated.
10. Tap the Achilles tendon
just above the heel.
9. Position client’s ankle Bending of the toes downward. There is the presence of toe- The response is normal.
firmly against the bed. curling.
Plantar (Babinski) 10. Slowly stroke client’s
sole with the handle of
the reflex hammer.
 Name: Ms. M
1. SKIN
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color Inspection Inspect variations in skin Color varies from light Her skin color is light There are no signs of
color under natural sunlight to to ruddy pink or dark brown. abnormalities.
ensure accuracy findings. brown, depending on the
race. Color is uniform
except for sun exposed
areas or normally
lighted pigmented areas
(nailbeds, palms, lips) in
dark skinned people.
Lesions Inspection Note for color, size, and Freckles, skin tags in Moles are present in There are no signs of
anatomic location and elderly, and some types the patient armpit, ears, abnormalities.
distribution. of birthmarks and moles and in her back.
are normal.
 Palpation Palpate lesions with finger
pads for mobility and contour
(flat, raised, or depressed) and
consistency (soft or durable)
Moisture Inspection Note amount and distribution Moisture varies with Her skin is soft and Her skin is oily due to
and Palpation activity, body and oily. naturally high moisture.
environmental
temperature, and
humidity in skin folds
and the axillae.
Temperature Palpation Palpate with dorsum of hand Temperature should be Her temperature is The patient temperature
noting for uniformity of uniform and within 36.9° is warm to touch.
warmth. normal range.
Texture (quality, Palpation Palpate with finger pads in Texture is not uniform Her palms are soft, and There are no signs of
thickness, different areas like the palms and soles the soles are thicker abnormalities.
suppleness) are thicker than any than any areas. And
areas. Wrinkled and there is no presence of
leathery skin in the any lesions.
elderly results from the
normal aging. Process
with decreased collagen,
subcutaneous fats, and
sweat glands.
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION

Mobility and turgor Palpation Assess mobility and turgor to Absence of indention is He skin quickly turns There are no signs of
(elasticity) measure elasticity of skin to dependent areas and the back to its original abnormalities.
determine the degree of resilience of the skin position in 1secs.
hydration. spring back to its
There’s no signs of
previous state after
edema.
being pinched.
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:
26. 0 = no pitting
27. 1+ = trace/mild
(2mm) pitting
28. 2+ = moderate
(4mm) pitting
29. 3+ = deep/severe
(6mm)
30. 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/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color and Inspect Assess for color and Color varies from black Her hair is evenly There are no signs of
Distribution distribution of scalp hair, to pale blonde based on distributed, and her hair abnormalities.
eyebrows, eyelashes, and the amount of melanin is black in color.
body surface. present.
Texture and oiliness Palpation Assess for the skin’s texture Thin, straight, coarse, Her hair is thin, oily Excessive application of
and oiliness with the use of thick, or curly. Hair is and shiny. hair product it lead to
palm. shiny and resilient oily.
infestation Inspection Assess for any presence of Free from any There are no presence There are no signs of
infestation by examining the infestation. lice or infestation. abnormalities.
hair and scalp.

3. SCALP
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Scaliness and scars Inspection Part the hair repeatedly all
over the scalp and inspect for
scaliness and scars.
Tenderness, lesions, Palpation Place finger pads on the scalp
lumps, masses at the front and palpate down
the midline and each side for
tenderness, lesions, lumps, or
masses.
The scalp should be Her scalp is clean and There are no signs of
shiny and smooth smooth, also there is no abnormalities.
without lesions, lumps, signs of any lesions or
or masses. masses.
Absence of redness or There is no tenderness, There are no signs of
scaliness. lesions, lumps, or abnormalities.
masses on the patient’s
scalp.

4. NAILS
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Color, shape, and Inspection Inspect for color and shape Nailbeds is highly Her nail bed is light There are no signs of
texture vascular with a pink pink and the shape of abnormalities.
color in light skinned the nail is round.
clients and longitudinal
streaks of brown or
black pigmentation in
dark skinned clients.
Angle between
fingernail and base is
about 160 degrees.
Her nails are smooth
 Palpation Palpate nailbed for firmness
and texture
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 firm.
Nailbed is firm
When pressure is Upon the release of There are no signs of
released from the nail, it pressure from the nail, abnormalities.
promptly returns to its it quickly returns to its
normal color. usual color in less than
1 second.
Tissue surrounding the The tissue surrounding There are no signs of
nail is intact. the nail remains intact abnormalities.
and free from any
lesions.

5. SKULL
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Shape and symmetry Inspection Inspect skull for shape, Rounded, symmetrical, Her skull is Upon examining her
symmetry, size in proportion normocephalic, and symmetrical skull indicates well-
to body and position. upright. normocephalic and it is proportioned and
rounded in shaped. symmetrical structure.
 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.
6. FACE
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
Facial features Inspection Inspect facial features for
expression, shape, and
symmetry of eyebrows,
placement of nose, eyes, and
ears.
Edema and masses Inspection Inspect for any presence of
edema and masses
7. EYES
Smooth, non-tender, free Her skull is smooth and There are no signs of
of masses or there’s no any signs of abnormalities.
depressions. masses, depressions or
tenderness palpated.
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
May be oval, round, or Her face is a square and There are no signs of
square. Symmetrical symmetrical in shape, abnormalities.
features and movement. with symmetrical
features such as
eyebrows, nose, eyes,
and ears.
No edema and masses There is no presence of There are no signs of
edema or masses on the abnormalities.
patient’s face.
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION

Visual Acuity Inspection Test visual acuity. Normal vision based on Her visual acuity is in There are no any signs
the Snellen chart is 20/20 normal 20/20 vision of abnormalities on her
36. Position Snellen chart 20
at the distance of 20 feet She hasn’t experienced visual acuity.
ft. in front of client.
37. Remove corrective the normal eye can read a blurry vision.
lenses, if appropriate. the chart).
38. Instruct client to cover
one eye and read lines
starting with top of chart
from left to right.
39. Note the line where client
reads more than half of
the letters.
40. Record results as a
fraction sc (without
correction), 20/ distance
number, and the number
of the letters missed.
41. Repeat same steps for the
other eye.
42. If appropriate, repeat
steps with patient
wearing the corrective
device.
Inspection Test eye for extraocular Eye movement should Her smooth eyes There are no signs of
muscle movements: be symmetrical as both movement is evident, abnormalities.
eyes follow the direction with both eyes
41. Place the client in sitting
of the gaze and smoothly following the
position.
42. Instruct the client to hold converge on the held gaze direction and
 head still. object as its moves converging on the
43. Ask the client to follow toward the nose. object as it moves
an object with eyes. closer to the nose.
44. Move objects with 6
fields of gaze.
***The 6 Fields of Gaze The upper eyelids cover Her upper eyelids cover Upon examination, her
only the uppermost part only her uppermost upper eyelid remains
31. Conjugate left lateral
of the iris and are free parts of the iris and has stable without any
gaze
32. Left down and lateral from nystagmus no signs of nystagmus, abnormal twitching or
gaze (involuntary rhythmical indicating a lack of oscillations.
33. Right down and lateral oscillation of the eyes). involuntary and
gaze A few beats of rhythmic movements in
34. Conjugate right lateral nystagmus with extreme the eyes.
gaze lateral gaze can be
35. Right up and lateral gaze normal.
36. Left up and lateral
45. Observe for parallel eye
movement.
46. Pause during upward and
lateral gaze field to detect
in voluntary rhythmic
oscillation of eyes.
47. Note position of upper
eyelid in relation to the
iris and eyelid bag as the
client’s eye move from
up and down.
48. Move object forward to
about 5 inches in front of
the client’s nose at the
midline and observe for
 convergence, and record
result.
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
External anatomical Inspection Observe upper eyelid.
structures
Check eyes and eyelids for
inflammation, crusting, edema Eyes and eyelids should
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.
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Upper eyelid should Her upper eyelid There are no signs of
overlap iris. margin overlaps the abnormalities.
iris.
be free from There is no presence of
inflammation, crusting, inflammation, edema,
edema or masses. or masses on her eye
and eyelids.
Her lacrimal glands
indicate no redness or
swelling.
Lacrimal gland should Her lacrimal gland is There are no signs of
not be palpable. not palpated, and the abnormalities.
tears flow easily from
the lacrimal gland to
Tears flow freely from the lacrimal duct
the lacrimal gland over through the cornea and
the cornea and conjunctiva.
conjunctiva to the
lacrimal duct.
Bulbar is transparent Her bulbar is clear and There are no signs of
with small blood with the presence of abnormalities.
vessels. small blood vessels.
p. Instruct client to look Palpebral conjunctiva Her palpebral
upward while depressing covering the inside of conjunctiva is moist
lower lid with thumb. the upper and lower and free from any
q. Inspect for color, redness, eyelids is pink and swelling.
swelling, exudates, or moist.
foreign bodies. Her sclera is white, and
r. Inspect cornea, lenses, Sclera is white with her cornea is
pupil, iris, and anterior some superficial blood transparent, moist and
chamber: vessels depending on the clear.
1. Stand in front of race.
the client.
2. Shine penlight
directly on cornea.
Corneas are moist, shiny
3. Move light
laterally and view and clear.
cornea from that Lenses are transparent.
angle; note color,
discharge, and Pupils are black, round
lesions. and equal diameter,
4. Look at pupil and ranging from 2-6mm.
note size and
shape. Entire iris should
5. Shine penlight illuminate when shining
directly on pupils light laterally too
to assess lens and nasally.
color.
6. Look at iris for
size, and ability of
pupils to react to
light.
7. Shine a light
obliquely through
 anterior chamber
from lateral side
toward nasal side.
Inspection Test for papillary response to Pupils should constrict Her pupils constrict the Her pupils are
light and reaction to quickly in direct direct reaction to light, simultaneous
accommodation in dimly lit response to light and the and the corresponding constriction in response
room. opposite pupil should pupil on the opposite to direct exposure to
also constrict. side also constrict. light. This coordinated
36. Instruct client to look
reaction suggests a
straight ahead. Pupil should be equal in The size of her pupil is
37. Bring penlight from healthy and
size. equal.
side of the client’s face to synchronized pupillary
directly in front of the Papillary response, indicative of
pupil. accommodation causes normal neurological
38. Note quickness or constriction in response function and visual
response to light. to objects that are near. pathways.
39. Shine light into same
eye observing for response Pupillary dilatation
or pupil for equality of occurs when pupils
size and repeat steps to the accommodate objects at
other eye. a distance, with
40. Instruct client to gaze symmetrical
at your finger held 4-6 convergence of eyes.
inches from her nose then
to glance at a distant
object while you note
papillary reflex.
41. Move finger toward
the bridge of client’s nose
noting response of both
pupil.
42. Record results
 PERRLA (pupils equal,
round, reactive to light
accommodation).

8. EARS
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
External ear Inspection Examine external ear, called Symmetrical, with upper Her ears are of equal Upon inspection, we
the auricle or pinna for attachment at eye corner size, the auricle is observed that her ears
placement, symmetry, color, level, and is fleshed properly aligned with demonstrate
discharge and swelling. colored. the corner of the eye, symmetrical
and the color of her proportions, with the
ears matches her skin auricle aligning
tone. appropriately with the
corner of the eye with
no signs of any
abnormalities.
Palpation Palpate the auricle between Firm, smooth, free from The auricle and pinna There are no signs of
the thumb and index finger lesions and pain. of the patient is any abnormalities.
noting lesions or tenderness smooth, firm and free
by moving auricle up and from any lesions or
down, same with the mastoid swelling.
tip.
Press inward on tragus noting
any tenderness.
Auditory acuity Inspection The Whispered Voice Test The client should be Her hearing is clear and There are no signs of
able to repeat whispered can repeat the
 21. Instruct the client to words. whispered words. abnormalities.
occlude one ear with
finger and repeat the
words when heard.
22. Stand 1-2 feet away
from the client, out of
view to avoid client
from lip reading, and
softly whisper
numbers on side of the
ears. Increase voice
volume until client
identifies uttered
number.
23. Repeat procedure on
other ear.
24. Record results.

9. NOSE AND SINUSES

AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION

Nose Inspection Inspect the nose for
symmetry, deformity, flaring,
or inflammation and
discharge from the nares.
Test patency of each nostril:
k. Instruct client to close
the mouth and apply
Located symmetrically, Her nose is We observed that she’s
midline of the face, and symmetrical, located in free from any lesions,
is without swelling, the proper position in swelling, or signs of
bleeding, lesions, or the face, and there are bleeding. And This
masses. no signs any lesions, indicates a normal nasal
swelling, or each of her condition.
nostril is patent.
 pressure on one nares Each nostril is patent.
and breathe
l. Repeat test on
opposite nares.
Nasal cavities Inspection Inspect the nasal cavity with a Mucosa is pink or dull Her septum is in the There are no signs of
penlight: without swelling or midline and intact, abnormalities.
polyps. mucosa is pink and
p. Tilt client’s head in an
there are no signs of
extended position. Septum is midline and
q. Place non dominant any bleeding or
intact.
hand on client’s head swelling.
using your thumb, and A small amount of clear
lift the tip of the nose. watery discharge is
r. With the lit penlight, normal.
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 None-tender air filled Her nasal sinuses are There are no signs of
on frontal and maxillary areas cavities. free from sensitivity or abnormalities.
avoiding pressure on the eyes. discomfort when we
touched or palpated.
Percuss area and note the
sound. We heard that there is
Resonant sound upon resonant sound upon
percussion. percussion.
 10. Mouth
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Breath Inspection Stand 12-18 inches in front of Breath should smell Her breath is fresh. Through good hygiene
client and smell the breath. fresh. her breath becomes
fresh.

Observe lips for color,

Lips Her lips are pink in
moisture, swelling, lesions There are no visible
color and free from any
lesions or abnormalities
k. Instruct client to open lesion.
present.
mouth and use tongue
depressor to retract Lips and mucosa should
buccal mucosa and be pink, firm, and moist
note color, hydration, without inflammation or
inflammation, or
lesions.
lesions.
l. 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 Gums are pink, smooth Her gums are pink, There are no signs of
and note color, edema, and moist. moist and firm. abnormalities.
retraction, bleeding and
lesions.
 Palpation Palpate gums with tongue
blade for texture
Ask client to clench teeth to
assess position and alignment
Teeth Inspection
with the use of a tongue
depressor, expose molars and
note for tartar, cavities,
extraction and color.
Inspection Instruct client to protrude
tongue:
16. Inspect dorsum of
tongue and note for
color, hydration,
texture, symmetry.
Tongue 17. With penlight, inspect
sides and ventral
surface and note for
size, texture, nodules,
or ulcerations.
18. Still with penlight,
inspect floor of mouth,
salivary glands, and
Palpation duct openings.
Grasp tongue with a gauze
and gently pull it to one side
and palpate full length of
tongue.
Gums are firm.
Teeth are properly Her teeth are properly There’s no signs of
aligned, smooth, white aligned, with a whitish abnormalities present.
and shiny. color, and there are
some spaces of tooth
on the left side.
When protruded, tongue Her tongue is in The dorsal surface of the
lays midline, medium midline, with the dorsal tongue appears smooth
red or pink in color, surface smooth and free and devoid of any
of lesion.
moist and smooth along lesions or abnormalities.
lateral margins, with
free mobility. Her tongue color is
pink and is smooth and
The dorsal surface is moist in texture.
slightly rough (taste
buds) and free from
lesions.
The ventral surface is
highly vascular, smooth,
moist, and free of
lesions.
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
Palate Inspection Inspect the soft and hard
palate with a penlight:
k. Instruct client to
extend head backward
and hold mouth open.
l. Inspect the hard palate
(roof of mouth) and
soft palate for color,
shape, lesions.
Inspection Inspect pharynx using tongue
depressor and penlight:
z. Explain procedure to
Pharynx
client.
aa. Instruct client to tilt
head back and open
mouth.
bb. With non-dominant
hand, place tongue
depressor on middle
third of tongue. With
the dominant hand,
shine light into back of
throat.
cc. Instruct client to say
“ah” and note position,
size, appearance of
tonsils and uvula.
dd. Inform client of
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Palates are concave and Her palates are concave There are no signs of
pink. and the soft palate is abnormalities.
smooth with a light
Hard palate has ridges.
pink coloration and her
Soft Palate is smooth. hard palate has ridges.
Also it is firm in
texture.
With phonation, the soft Her pharynx and tonsil Upon inspection it is
palate and uvula rise are pink in color and noted that the patient's
symmetrically. there are no signs of pharynx and tonsils
any lesions. exhibit a normal and
The pharynx is pink,
healthy appearance. The
vascular, lesion free.
coloration is described
Tonsil size is evaluated as pink, which is
using the grading scale. indicative of the typical
hue of these structures.
 eliciting gag reflex by
touching the posterior
1/3 of tongue with
tongue blade if palate
and uvula fail to rise
symmetrically with
phonation.

11. NECK
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
Inspection Instruct client to:
Symmetry and k. Flex chin to chest and
Musculature to teach side and
shoulder to test
anterior
sternocleidomastiod
muscle.
l. Hyperextend the neck
backward to test
posterior trapezia.
Palpation Palpate lymph nodes and
instruct client to relax and
flex neck slightly forward.
16. Stand in front of
seated client.
17. Methodically palpate
Lymph nodes both sides of face and
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Muscles are Her muscles exhibit We observed that her
symmetrical with head symmetry, and the head neck demonstrates
in central position. is centrally positioned. unrestricted movement,
and there are no
Movement though full Her neck movement
reported complaints of
range of motion without can move freely
discomfort.
complaint of discomfort without any complaints
or limitation. of discomfort.
Lymph nodes should not Her lymph nodes are There are no signs of
be palpable. Small, not palpable. abnormalities.
movable nodes are
insignificant.
 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.
18. Note size, shape,
mobility, consistency
and tenderness.
Trachea Inspection Note for position. Midline position above Her trachea is located We observed that her
the suprasternal notch. in a midline position trachea is appropriately
above the suprasternal situated in the midline
Palpation Place thumbs and index finger notch. And there is no position above the
on sides of trachea and apply pain upon palpation. suprasternal notch. And
gentle pressure and palpate. there is no reported pain
upon palpation,
indicating that the
trachea is not tender or
sensitive to touch.
Palpation With client seated, assessment Thyroid cannot be Her thyroid is non There are no signs of
may be done with posterior visualized. tender and has a soft abnormalities.
and anterior approach: texture when touched.
K. POSTERIOR
APPROACH It may or may not be
Thyroid
1. Stand behind client felt. No bruits on
and place thumbs auscultation.
on nape of neck and
bring fingers
 interiorly around If felt, it should be
neck with their tips smooth, soft, non-tender
resting over tracheal and not enlarged.
rings.
2. Ask client to tilt
chin forward to
relax neck muscles
and swallow.
3. Palpate the isthmus
rise under fingers
and feel each lateral
lobe before and
while client
Auscultation 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
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.
L. 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/FEATURE TECHNIQUE SKILLS
TO ASSESS
Inspection Place client in sitting position
with arms folded across chest,
back exposed.
11. Assess shape and
symmetry by taking note
of the rate and rhythm of
Shape, symmetry, respirations, movement of
and diameter chest wall with deep
inspiration and full
expiration.
12. Estimate anteroposterior
diameter in proportion to
lateral diameter.
Lesions Palpation 21. Palpate for lesions or
areas of pain.
22. Palpate thoracic
expansion at 10th rib by
placing thumb close to
client’s spine and spread
hands over thorax. Note
divergence of thumbs;
feel for range and
symmetry of movement
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Respirations are quite, The respiration rate is Theirs is no signs of any
effortless, and regular, 17 breaths per minute. abnormalities upon
with 12-20 breaths per The thorax moves observing her
minute. smoothly and quietly respiratory rate.
during inhalation and
Thorax rises and falls in
exhalation. No
unison with respiratory
deformities are
cycle.
detected upon
Ribs slope across and palpation.
down, without
movement or bulging in
the intercostals spaces.
Thumb should separate Upon palpation, there The findings indicates
an equal distance of 3- are no lesions or that there are no
5cm and in the same tenderness detected on noticeable
direction during thoracic the posterior thorax. abnormalities, skin
expansion and meet in irregularities, or areas of
The symmetry of
the midline on discomfort on the back
movement is evident
expiration. of the thoracic region.
while palpating the
thoracis expansion.
Posterior thorax is free Fremitus is symmetric We observed that the
 during deep inhalation
and full exhalation.
23. Place ulnar aspect of open
hand at right apex of lung
and place hand at each
posterior thorax location.
Then instruct client to say
“99” and palpate for
tactile fremitus
(vibrations caused by
vibrations). Note areas of
increased and decreased
fremitus.
24. 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.
11. Start at lung apices by
moving hands from side
to side across the top of
Sound Percussion each shoulder. Note sound
produced from each
percussion strike and
compare with
contralateral sound.
12. Continue downward and
post lateral every other
intercostals space. Note
intensity, pitch, duration,
from tenderness, lesions and easily identified in symmetry of movement
and pulsations. the upper region of the during palpation of the
lungs. It is equal on thoracic expansion
both sides of the indicates a balanced and
Fremitus is equal on thorax. uniform expansion of
the chest.
both sides of thorax,
strongest at the level of
We also observed that
tracheal bifurcation.
the fremitus, are evenly
distributed and readily
noticeable in the upper
portion of the lungs. The
symmetry in fremitus
implies a balanced and
uniform transmission of
vibrations during
palpation, particularly in
the upper respiratory
regions.
Air filled lungs create a Upon percussion, The presence of
resonant sound. resonant sound is resonant sounds during
heard. percussion on the thorax
and lung assessment is a
positive indication.
Resonance is a normal
and expected sound,
Identify contralateral suggesting that the
sound; bones create flat underlying lung tissue is
sound. Thorax is more air-filled and healthy.
resonant in children and
 and quality of percussion. thin adults.
Breath sounds Auscultation 21. Place diaphragm of Posterior sound: No adventitious Upon auscultation, there
stethoscope on right lung vesicular and sounds, such as is no abnormal sounds,
apex. Instruct client to bronchovesicular. crackles or wheezes are such as crackles or
inhale and exhale deeply auscultated. wheezes, were detected.
and slowly when
stethoscope is felt on the
Lateral sound: vesicular
back. Repeat on left lung
apex.
22. More downward every
other intercostals spaces A large chest will
and auscultate, placing produce decreased
stethoscope in the same breath sound.
position on both sides.
23. 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.
24. Repeat last step on the left
side.

B. ANTERIOR THORAX
AREA/FEATURE TECHNIQUE SKILLS
TO ASSESS
Inspection Place client in sitting position
or supine position. Inspect
client’s chest for:
Symmetry, rhythm
11. Symmetry and depth
and slope
of movement.
12. Slope of ribs and
musculoskeletal
deformities.
Tenderness, Palpation 16. Place fingerpads on Same normal findings
pulsation, masses right apex above the with posterior palpation.
and crepitance clavicle. Proceed
downward to each rib
and intercostals space
and note for
tenderness, pulsation,
masses and crepitance.
Repeat on left side.
Respiratory 17. Assess respiratory
excursion excursion by placing
thumbs along each
costal margin with
hands on lateral rib
cage. Instruct client to
NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
INTERPRETATION
Thorax rises and falls in Her respiration rate is 16 We observed that the
unison with respiratory breaths per minute and respiration rate of 16
cycle, ribs at 45 degrees the thorax moves breaths per minute
angle with sternum. smoothly and quietly which indicates a
Inspiratory breath during inhalation and normal and steady
sounds are not audible at exhalation. breathing pattern. The
a distance of more than smooth and quiet
2to 3 cm from mouth. movement of the
anterior thorax during
both inhalation and
exhalation indicates
proper respiratory
function.
There is no presence of The findings indicates
tenderness or pain that there are no
palpated over the area. noticeable
abnormalities, skin
irregularities, or areas
of discomfort on the
back of the thoracic
region.
Fremitus is symmetric Fremitus is symmetric
and easily identified. It and easily identified
is equal on both sides. which is normal.
 inhale deeply; note for
divergence of thumbs
on expansion; feel
range and symmetry
of respiratory
Tactile Fremitus movement.
18. Palpate for tactile
fremitus. Gently
displace female
breasts as necessary.
Percussion Percuss anterior surface by: Resonant sound over Percussion elicits Upon percussion and
lung tissue dullness over breast auscultation, the
6. Percuss 2-3 strikes
(hyperresonance in tissue, the heart, and the symmetry and sound
along right lung apex
and repeat on left lung children and thin adults) liver. are found normal.
apex. Proceed Cardiac, liver, and
downward, percussing gastric silhouettes emit
in every ICS going dull sound.
from right to left in
same positions on both Ribs emit flat sound.
sides.

Symmetry and
sound Assess each thorax area:
21. Resonant lung filled.
22. Cardiac dullness: 3rd-
5th ICS left of sternum.
23. Liver dullness: place
finger parallel to upper
border of expected
liver dullness in right
midclavicular line;
 percuss downward.
24. Gastric air bubble:
repeat procedure done
on liver dullness on
the left side.

Auscultate anterior surface by

instructing client to breath
Auscultation Anterior sounds: Tympany is detected There are no signs of
through the mouth and
bronchial, over the stomach, and abnormalities.
compares symmetrical areas
bronchovesicular, flatness is detected over
of lungs from above
vesicular. the bony prominence.
downward:
A large chest will
16. Listen to breath
produce decreased
sounds and note
intensity and identify breath sounds.
variations from
normal.
17. Identify any added
sounds by location on
chest wall and time in
the respiratory cycle.
18. If breath sounds are
diminished, ask client
to breath hard and fast
with mouth open.

13. CARDIOVASCULAR
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Arterial Pulses Palpation Compress the radial artery
with your index finger and
middle finger.
Heart Inspection Precordial Movement
1. Position the patient supine
with the head slightly elevated
2. Always examine from the
Palpation patient's right side.
3. Palpate for point of
maximal impulse. (Normally
located at 4th or fifth ics,
1mcl)
Auscultation 4. Listen with diaphragm at
the right 2nd ICS
5. Listen to the 2nd ICS near
the sternum.
6. 3rd, 4th, 5th ICS near
sternum
7. Listen for apex
Tissue perfusion Palpation Perform the Allen Test to
determine patency of radial
and ulnar arteries. Instruct
client to rest hands on lap.
Normal Heart rate Upon palpation, the Pulse rate of 90bpm
patient’s pulse rate is 90 falls within a moderate
beats per minute. range and is generally
considered within the
normal adult heart rate
range.
When the patient was Upon inspection, the There are no signs of
auscultated, the chest appears abnormalities.
pulsation in the mitral symmetrical without
area can be palpable and visible abnormalities or
when no signs of deformities.
irregular rhythm and
murmur sounds.
Upon palpation, the
pulse is regular and
strong, and the point of
maximal impulse is
palpable at the apex,
usually at the fifth
intercostal space in the
midclavicular line.
Upon auscultation, heart
sounds are clear and
well-defined.
Palms should turn pink The palm and fingers There are no signs of
promptly. quickly regain their abnormalities.
normal color, indicating
good blood flow through
 1. Compress both the radial the released artery.
and ulnar arteries.
2. Firmly compress arteries
and instruct clients to open
their hands.
3. Note the color of the palms.
4. Release one artery and note
the color of the palm.
5. Repeat steps on other
arteries on the same hand.

14. ABDOMEN
AREA/FEATURE TECHNIQUE SKILLS NORMAL FINDINGS KEY FINDINGS ANALYSIS AND
TO ASSESS INTERPRETATION
Generalized Inspection Placing client in supine Contour is flat or Her abdomen is evenly Her abdomen is evenly
appearance of position with knees flexed rounded and bilaterally round, bulky and there round and has a
abdomen over a pillow, hands at side or symmetrical. are striae detected due to significant asymmetry
over the chest, undrape gain weight. or bulging. The
patient from xiphoid process presence of striae, often
Her umbilicus is in the
to symphysis pubis to expose Umbilicus is depressed associated with her
midline, and the skin
abdomen. and beneath the gaining weight.
color is same to the
abdominal surface.
21. Inspect abdomen surrounding abdominal
from rib margin to skin tone.
pubic bone and note There are no signs of
for contour and Visible peristalsis is Her abdomen is smooth abnormalities on the
symmetry. slowly transverses the and it is even respiratory abdomen of the client.
22. Inspect umbilicus abdomen in slanting movements.
for contour, location, downward movements
 signs of as observed in thin No abnormal
inflammation or client. Pulsations of the respiratory movements
hernia. abdominal aorta are are observed.
23. Observe for smooth, visible in the epigastric
even respiratory area in thin clients.
movements.
24. Observe for surface
motions (visible
peristalsis)
Bowel sounds Auscultation Auscultate the bowel sounds High pitched sounds Bowel sounds are The presence of audible
on the abdominal quadrants heard every 5 to 15 audible in various bowel sounds in
using the diaphragm of the seconds as intermittent abdominal quadrants, as various abdominal
stethoscope. gurgling sounds in all 4 they represent the quadrants indicates
quadrants as a result of movement of contents normal gastrointestinal
16. Begin by placing the
fluid and air movement through the stomach. motility.
diaphragm on the
RLQ. Listen for a in GIT.
full minute to the
frequency and
character of bowel
movements.
17. Repeat same step
proceeding in Bowel sounds should
sequence to RUQ, always be heard at the
LUQ, and LLQ. ileocecal valve.
18. Listen at least for 5
minutes before
concluding the
absence of bowel
sounds.
Abdominal Percussion Begin percussion in RLQ, Tympany is heard Tympanic sounds are Tympanic sounds over
quadrants move upward to RUQ, cross because of air in the over air-filled structures air-filled structures
 over to LUQ, and down to
LLQ. Note when tympani
changes to dullness.
stomach and intestines. like the stomach and such as the stomach
Dullness is heard over intestines and a hollow, and intestines indicate
organs. drum-like sound is normal findings during
produced upon abdominal percussion.
percussion.

15. NEUROLOGIC SYSTEM

ASSESSMENT OF COMMON DEEP TENDON REFLEX
TYPE ASSESSMENT NORMAL REFLEX KEY FINDINGS ANALYSIS AND
INTERPRETATION
16. Flex client’s arm No difficulties detected. The bicep reflex is
between 45 degree normal.
Biceps angle and 90 degree. There should be flexion of arm
17. Place thumb firmly on at elbow.
biceps tendon just
above the crease of
antecubital fossa.
18. Tap thumb with reflex
hammer.
Triceps 11. Flex client’s arm at 45 Extension of elbow When the triceps tendon is The contraction of the
degree and 90 degree tapped, the forearm extends triceps muscle is normal.
angle. at the elbow joint.
12. Tap triceps tendon just
above the elbow.
11. Flex client’s arm at 45 Flexion of forearm Forearm flexion is present. Normal forearm flexion.
degree angle and place
on lap with the arm
 Brachioradialis semipronated.
12. Tap brachioradialis
tendon on thumb side
of the wrist.
11. Ask the client to sit in a Extension of leg below the The quadriceps muscle Normal leg extension and
chair or on edge of bed knee. contracts as the knee quadriceps muscle
Patellar with legs hanging stretches. contraction.
freely or in supine
position with knee
flexed.
12. Tap patellar tendon just
below the patella.
11. Ask client to sit with Plantar flexion of foot. Plantar flexion is present. The plantar flexion of the
feet dangling and foot is normal.
Achilles partially dorsiflexed or
in a supine position
with legs flexed at knee
and thigh externally
rotated.
12. Tap the Achilles tendon
just above the heel.
11. Position client’s ankle Bending of the toes downward. There is the presence of toe- The response is normal.
firmly against the bed. curling.
Plantar (Babinski) 12. Slowly stroke client’s
sole with the handle of
the reflex hammer.