BODY PART SKIN

NORMAL FINDINGS -light to dark brown and feels warm -no swelling -good skin turgor Smooth and soft

HAIR

NAILS

-smooth and soft -colour black -properly distributed -no presence of lice -fine texture -no masses -no tenderness -round nail with 160 degrees nail base -good capillary refill -face is symmetrical, centred - head position -face is oval, round, square, heart shaped -facial hair equally distributed -can raise brows, frown, close eyes, show teeth, smile, puff cheeks (7th cranial nerve FACIAL). Symmetrical facial expression dependent on the

ACTUAL FINDINGS -light to dark brown and feels warm -with dark spots -good skin turgor -smooth and soft -smooth and soft -scalp is free from masses and lumps -no tenderness

ANALYSIS AND INTERPRETATION -normal findings

-normal findings

HEAD AND FACE

-round nail with 160 degrees nail base -good capillary refill -face is symmetrical

-normal findings

-normal findings

-face is oval Facial hair equally distributed -symmetrical facial expression dependent on the mood

mood -smooth and controlled movements -no tenderness, masses or deformities

-smooth and controlled movements -no tenderness, masses or deformities

EYES

-blinking symmetrical, involuntary and approximately 15 blinks/min -eyebrows are evenly distributed -eye lashes are short -eye lid margins moist and pink -pupil is equally round and reactivated to light accommodation -iris is uniform in colour, transparent, smooth, moist -symmetrical, matches the colour of skin, in line with the inner/outer canthus of the eyes -no discharges or lesions -no tenderness, masses or lumps

-blinking symmetrical, involuntary and approximately 15 blinks/min -eyebrows are evenly distributed -eye lashes are short -eye lid margins moist and pink

-normal findings

EARS

-iris is uniform in colour, transparent, smooth, moist -symmetrical, matches the colour of skin, in line with the inner/outer canthus of the eyes -no discharges or lesions -no tenderness,

-normal findings

-can hear whispers in a distance of 2 feet (acoustic nerve) -(-) Webers test or n lateralization -(+) Rinnes test or air conduction is greater than bone conduction

NOSE

MOUTH AND PHARYX

masses or lumps -can hear whispers in a distance of 2 feet (acoustic nerve) -(-) Webers test or n lateralization -(+) Rinnes test or air conduction is greater than bone conduction -proportionate -proportionate -flat or pointed, -nasal bridge is straight, or straight at crooked or curved, midline at midline nasal bridge -patent -patent -no tenderness in -no tenderness the frontal and in the frontal maxillary sinuses and maxillary sinuses -with mole at the left lower portion of the nose -lips are pink in -lips are pink in colour colour -buccal mucosa is -buccal smooth, moist mucosa is with no lesions smooth, moist -gums are pink with no lesions and moist -gums are pink -no dental carries and moist -32 complete no. -no dental of teeth carries -symmetrical, no masses, no scars, -symmetrical, no masses, no

-normal findings

-normal findings

NECK

-normal findings

proportionate, freely movable without difficulty, neck vein engorgement not evident -non palpable for lymph nodes

SPINE

-spine straight and mobile -no tenderness, no masses, no lumps

scars, proportionate, freely movable without difficulty, neck vein engorgement not evident -non palpable for lymph nodes -lodging of bone fragments in the spine -presence of kyphosis

- The spine should be aligned vertically and in midline. -The spine has abnormal curvature because theres lodging of bones. -normal findings

THORAX/LUNGS

-position of sternum is level with ribs -no masses -lungs clear upon auscultation

CARDIOVASCULAR/HEART -PMI is felt upon auscultation -rhythm is regular

BREAST AND AXILLA (OPTIONAL)

-smooth skin surface -flat areola -absent thickening or edema, no tenderness, free of masses, tumor or lesions -no rashes or lesions

ABDOMEN

-position of sternum is level with ribs -no masses -lungs clear upon auscultation -PMI is felt upon auscultation -rhythm is regular -smooth skin surface -flat areola -absent thickening or edema, no tenderness, free of masses, tumor or lesions -no rashes or lesions

-normal findings

-normal findings

-normal findings

-umbilicus is centrally located -rounded abdomen -symmetrical -high pitched, irregular gurgles 5-35times/min -abdomen rides with inspiration in synchrony with chest

MUSCULOSKELETAL

-upright posture, good alignment, no evidence of abnormal spinal curvature -symmetrical musculature, equal strength bilaterally. No atrophy, hypertrophy or masses noted -symmetrical joints, full ROM head, neck, spine, upper and lower extremities -no swelling, tenderness or crepitation -bones symmetrical aligned -no tenderness, masses

-umbilicus is centrally located -rounded abdomen -symmetrical -high pitched, irregular gurgles 535times/min -abdomen rides with inspiration in synchrony with chest -evidence of abnormal spinal curvature -lodging of bone fragments -atrophy noted

-- The spine should be aligned vertically and in midline. -The spine has abnormal curvature because theres lodging of bones.

-asymmetrical joints

-bones asymmetrically aligned

GENITALS (OPTIONAL)

-urethral meatus, slit like

Not assess

RECTUM AND ANUS (OPTIONAL)

appearance and in midline -no swelling or pain -no indurations, purulent discharges -slightly darken dark pink to brown, smooth and puckered, skin tags are rare and are normal

Not assess