PHYSICAL EXAMINATION

VITAL SIGNS NORMAL FINDINGS ASSESSMENT

BP <120 / <80 130/70 mmHg Normal

PR 60-100 92bpm Normal

RR 16-20 20cpm Normal

Temp 36.5-37.5 36.0 C Normal

INITIAL TECHNIQUE NORMS FINDINGS ANALYSIS AND

ASSESSMENT INTERPRETATION
Body built, height and Inspection Proportionate, varies with lifestyle Proportionate, his BMI is ABNORMAL
weight in relation to higher than normal Due to unhealthy Diet
clients age and Lifestyle
Posture while sitting Inspection Relaxed, erect, posture, Relaxed, erect, posture, NORMAL
coordinated movement coordinated movement
Body and breath odor Inspection No body odor or minor odor No body odor and breath NORMAL
(talking with the relative to work, or exercise; no odor
patient) breath odor
Signs of distress in Inspection No distress noted No distress noted NORMAL
posture or facial
expression
Signs of health and Inspection Healthy appearance The client appears just a little ABNORMAL
illness weak Due to his present
 condition
Clients attitude Inspection Cooperative, able to follow The patient was cooperative NORMAL
instructions
Clients affect/ mood; Inspection Appropriate to the situation The patient answers NORMAL
appropriateness of questions coherently without
clients responses assistance
Quantity of speech, Inspection Understandable, moderate pace, Understandable, moderate NORMAL
quality and organization clear tone, exhibits thought and clear
association

Relevance and Inspection Logical sequence, makes sense, Makes sense and has sense NORMAL
organization of thoughts has sense of reality of reality

I. SKIN
AREA TECHNIQUE NORMS FINDINGS ANALYSIS AND
INTERPRETATION
Skin color Inspection Varies from light to deep brown; Uniform skin color NORMAL
from yellow overtones to olive
Uniformity of skin color Inspection Generally uniform except in Uniform in skin color NORMAL
areas exposed to the sun; areas
lighter pigmentation (palms, lips,
nailbeds) in dark skinned
Assess edema Inspection No edema No edema NORMAL
Skin lesions Inspection Freckles, some birthmarks, no (+) gangrene on left foot, (+) ABNORMAL
abrasions or other lesions non-healing wound at the right Due to present
anterior leg condition
Skin moisture Inspection Moisture in skin folds and Skin is dry ABNORMAL
axillae Due to dehydration.

II. HAIR
AREA TECHNIQUE NORMS FINDINGS ANALYSIS AND
INTERPRETATION
Evenness of the growth, Inspection Evenly distributed and covers There are noticeable areas of NORMAL
thickness or thinness of the whole scalp baldness Part of Aging Process
hair
Texture and oiliness Inspection Silky, resilient hair Silky resilient hair, with NORMAL
over the scalp grayish strands Part of Aging Process
Presence of infection Inspection No infection and infestation No Infection and Infestation NORMAL
and infestation
Amount of body hair Inspection Variable Variable. No abnormal hairines NORMAL
on other parts of the body

III. NAILS
AREA TECHNIQUE NORMS FINDINGS ANALYIS AND
INTERPRETATION
Fingernail plate shape Inspection Convex, curvature; angle of nail Convex NORMAL
plate
Fingernail and toenail Inspection Smooth texture Smooth texture NORMAL
texture
Fingernail and toenail Inspection Highly vascular and pink in light Brown pigmentation in NORMAL
bed color skinned clients; dark skinned longitudinal streaks
clients may have brown or black
pigmentation in longitudinal
streaks
Tissues surrounding Inspection Intact epidermis Intact epidermis NORMAL
nails
Blanch test of capillary Inspection, Promptly return of pink or usual Less than 4 seconds NORMAL
refill palpation color (generally less than 4
seconds)

IV. HEAD
AREA TECHNIQUE NORMS FINDINGS ANALYSIS AND
INTERPRETATION
Size, shape and Inspection Round (normocephalic with The clients head is round, NORMAL
symmetry of the skull symmetrical frontal, parietal, and normocephalic with
 occipital prominences) smooth symmetrical frontal, parietal,
skull contour and occipital prominences
Ppresence of nodules, Inspection and Smooth uniform consistence; Smooth, absence of nodules or NORMAL
masses and depressions palpation absence of nodules, or masses masses
Presence of edema and Inspection and No edema and hollowness No edema or hollowness NORMAL
hollowness in the eye palpation

V. EYES
AREA TECHNIQUE NORMS FINDINGS ANALYSIS AND
INTERPRETATION
Color, texture and Inspection Pinkish in color with presence of Pinkish in color with presence NORMAL
presence of lesions in small capillaries; moist, no of small capillaries; moist, no
the palpebral foreign bodies foreign bodies
conjunctiva
Ssclera: color and clarity Inspection White in color; clear, no White in color; clear, no NORMAL
yellowish discoloration, some yellowish discoloration, some
capillaries may be visible capillaries may be visible
Iris: shape and color Inspection Anterior chamber is transparent; Anterior chamber is NORMAL
no noted visible materials, color transparent; no noted visible
depends on the persons race materials, black in color
Cornea: clarity and Inspection No irregularities on the surface, No irregularities on the NORMAL
texture looks smooth, clear or surface; clear
transparent
Pupils: color, shape and Inspection Color depends on persons race; Black, equal in size; equally NORMAL
symmetry of size size ranges from 3- 7 mm; and round; 3mm in size
are equal in size; equally round
light reaction and Inspection Constrict briskly/ sluggish Constricts briskly NORMAL
accommodation
Visual acuity Inspection
Lacrimal gland: Palpation No edema or tenderness over No edema or tenderness NORMAL
palpability and lacrimal gland
tenderness of lacrimal
gland
Extraocular muscles eye Inspection Both eyes coordinated, moved in Both eyes are coordinated in NORMAL
alignment unison with parallel alignment movement; parallel alignment
Visual fields: peripheral Inspection When looking straight ahead the Patient sees objects in NORMAL
visual fields client can see objects in the periphery
periphery

VI. EARS
AREA TECHNIQUE NORMS FINDINGS ANALYSIS AND
INTERPRETATION
Auricles: color, Inspection Color same as facial skin; Aligned with outer canthus of NORMAL
symmetry of size and symmetric; auricle aligned with the eye, same color as facial
position outer canthus of the eye; about skin, both auricle are
10 degrees from vertical symmetrical
Texture, elasticity and Inspection and Mobile, firm and not tender, Mobile firm and not tender; NORMAL
areas of tenderness palpation pinna recoils after it is folded pinna recoils after folded
Hearing acuity test: Inspection Normal voice tones audible The client can hear whispered NORMAL
client response to voices
normal voice tones

VII. NOSE
AREAS TECHNIQUES NORMS FINDINGS ANALYSIS AND
INTERPRETATION
Any deviation in shape, Inspection Symmetric and straight; no Symmetric and straight; no NORMAL
size or color and flaring discharge; uniform in color discharge; uniform in color;
or discharge from nares not flaring and has no
discharge
Nasal septum (between Inspection Nasal septum intact and in Nasal septum is in midline and NORMAL
the nasal chambers) midline intact
Patency of both nasal Inspection Air moves freely as the client Air moves freely in both nares NORMAL
cavities breathes through the nares
Tenderness, masses and Palpation Not tender; no lesions No lesions, not tender NORMAL
displacement of the
bones and cartilage
Sinuses: identification of Palpation not tender Not tender NORMAL
the sinuses for
tenderness

VIII. MOUTH
AREA TECHNIQUE NORMS FINDINGS ANALYSIS AND
INTERPRETATION
Lips: symmetry and Inspection Uniform pink color, soft, moist, Uniform pink color, soft, ABNORMAL
contour, control and smooth texture, symmetry of moist, smooth texture, Due to dehydration
texture contour, ability to purse lips symmetry of contour, ability to
purse lips; his lips appear a
little dry
Buccal mucosa Inspection Pink color, moist, smooth, soft Pink color, moist, smooth, soft NORMAL
glistening and classic texture glistening and classic texture
Gums: color and Inspection Pink gums; no retraction Pink gums; no retraction NORMAL
condition
Tongue/ floor of the Inspection Pink color; moist, slightly rough; Pink color; moist, slightly NORMAL
mouth: color and texture thin; whitish coating; moves rough; thin; whitish coating;
of the mouth and freely; no tenderness moves freely; no tenderness
frenulum
Position, color, and Inspection Central position, pink in color, Pink in color; smooth tongue; NORMAL
texture, movement and smooth tongue, base with base with prominent veins
base of the tongue prominent veins
Any nodules, lymph Inspection Smooth with no palpable Smooth with no palpable NORMAL
nodes or exocrated areas nodules lumps or excoriated nodules
areas
Plates and uvula: color Inspection and Light pink, smooth, soft palate, Soft palate, lighter pink hard NORMAL
shape texture and palpation lighter, pink hard palate, move palate
presence of bony irregular texture
prominences
Position of the uvula and Inspection Positioned in midline of soft Positioned in midline NORMAL
mobility (while examing palates
the palates)
Oropharynx and tonsil: Inspection Pink, smooth posterior wall Smooth posterior wall NORMAL
color and texture
Size, color and discharge Inspection Pink and smooth posterior wall Smooth posterior wall NORMAL
of tonsils
Gag reflex Inspection Present Present NORMAL

IX. THORAX
AREA TECHNIQUES NORMS FINDINGS ANALYSIS AND
INTERPRETATION
Anterior thorax: Inspection Quiet, rhythmic, and effortless Effortless respiration NORMAL
breathing patterns respiration
Temperature, tenderness Palpation Skin intact, uniform temperature, Uniform temperature; no NORMAL
and masses chest wall intact; no tenderness; tenderness or masses
no masses
Anterior thorax Auscultation Bronchovesicular and vesicular Bronchovesicular NORMAL
auscultation breath sounds
Posterior thorax: shape, Inspection Anteroposterior to transverse Anteroposterior to transverse NORMAL
symmetry and diameter in ration 1;2 chest diameter; symmetric
comparison of symmetric
anteroposterior thorax to
transverse diameter
Spinal alignment Inspection and Spine vertically aligned Spine aligned vertically NORMAL
palpation
Posterior thorax Auscultation Bronchovesicular and vesicular Bronchovesicular NORMAL
auscultation breath sounds

X. ABDOMEN
AREA TECHNIQUE NORMS FINDINGS ANALYSIS AND
INTERPRETATION
Skin integrity
Abdominal contour
Enlargement of liver or
spleen
Symmetry of contour
Abdominal movements
associated with
respiration, peristalsis or
aortic pulsations
Vascular pattern
Inspection Unblemished skin, uniform color Uniform color, unblemished NORMAL
skin
Inspection Flat, rounded (convex), scaphoid Rounded NORMAL
(concave)
palpation No evidence of enlargement of No evidence of enlargement of NORMAL
liver or spleen spleen or liver
Inspection Symmetric contour Symmetric contour NORMAL
Auscultation Symmetric movements caused Symmetric movement NORMAL
by respiration; visible peristalsis
in very lean people; aortic
pulsations in thin persons at
epigastric area
Inspection No visible vascular patter No visible vascular pattern NORMAL

XI. MUSCULOSKELETAL SYSTEM

AREAS TECHNIQUE NORMS FINDINGS ANALYSIS AND
INTERPRETATION
Muscle size and Inspection Proportionte to body; even in Proportionate to body, equal NORMAL
comparison on the other both sides strength on both sides
side
Fasciculation and Inspection No fasciculation and tremors No fasciculation and tremors NORMAL
tremors in muscle
Muscle tonicity Inspection Even and firm in muscle tone Even and firm in muscle tone NORMAL
Muscle strength Inspection Has equal strength on both sides Has equal strengths NORMAL

XII. JOINTS
AREA TECHNIQUE NORMS FINDINGS ANALYSIS AND
 INTERPRETATION

Joint swelling Inspection and No swelling; no warmth, no Pain on shoulder joints ABNORMAL
palpation redness, no pain, no crepitus Due to lack of activity
Extremities Inspection and No swelling, no warmth, no (+) gangrene on left foot, (+) ABNORMAL
palpation redness, no pain non-healing wound on the Due to present
right anterior leg Condition