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General conscious, coherent, Vital signs - BP- 110/40mmhg PR-98bpm RR-25 Body Part Techniqu Normal Findings e used Skin Inspectio Uniform in color, no abrasions or n any lesions Well moistened skin.
Skull & Face
Temp-36.5 Actual Findings Uniform in color, dry and rough skin with wrinkles and age spots due to aging Round or normocephalic; No any presence of masses or nodules; symmetrical facial movements Evenly distributed. No presence of pediculosis. Evenly distributed and eyebrows symmetrically aligned Lids closes symmetrically; Skinny smooth, yellowish conjunctiva; no edema or tenderness. Equally distributed Closed symmetrically, Skin intact, no discharge, no discoloration.
Inspectio n Palpation
No abnormal findings
Hair Eyebrow
Inspectio n Inspectio n
Even distribution of hair. Resilient think hair with no signs of infections or infestations Even distributed hair, Eyebrows symmetrically aligned; Lids close symmetrically; Skinny smooth, pinkish conjunctiva; no edema or tenderness. Equally distributed, curled slightly outward Skin intact, no discharge, no discoloration, lids closed symmetrically.
No abnormal findings
Pupils(color, shape,
No abnormal findings
Black in color, equal in size, normally 3-7ml in diameter, round smooth boarder, iris flat and round. Color same as facial skin Symmetrical; mobile, firm and not tender; no notable discharges. Normal voice tones audible
Equally in size No presence of lesions and discharges. Normal voice tones audible. No abnormal findings
Inspectio n
Symmetric and straight; No discharge or flaring: not tender, no lesions. Uniform in color Air moves freely as the patient breaths through the nares. No tenderness in maxillary and frontal sinuses
Symmetrical and straight; Without any presence of discharges and lesions. Breaths freely. No tenderness in maxillary and frontal sinuses Symmetrical lips; slightly dry lips Normal in position but with whitish in color.
No abnormal findings
Mouth Tongue
Inspectio n Inspectio n
Uniform in pink color; Symmetrical lips In central position; pink in color Moves freely with no tenderness Smooth tongue base with prominent veins, smooth with no palpable nodules.
Teeth
No dentures
No abnormal findings
Inspectio n Neck muscles Lymph nodes Upper extremities Palpation Inspectio n Palpation Inspectio n Palpation
32 adult teeth, smooth, white, shiny tooth enamel No retraction of gums Coordinated, smooth movement with no discomfort. Not palpable Muscle; equal size on both sides of the body. No contractures Bones; no skeletal deformities. Joints; no swelling, tenderness, crepitation or nodules. Moves freely Posterior thorax: Symmetrical; spine vertically aligned; Hips are the same in height. Skin intact; uniform temperature. No tenderness and no presence of masses Vesicular and bronchovesicular breath sounds Anterior thorax: Quite, rhythmic, and effortless respirations; No tenderness and no presence of masses Coordinated movement without any discomfort No palpable mass No contractures and deformities. Moves freely. No abnormal findings No abnormal findings
Normally aligned; skin intact and no presence of masses. Accelerated breathing with productive cough.
Abnormal findings
Abdomen
Inspectio
Abnormal findings
n Auscultati on Percussio n Palpation Lower Back Lower Extremities Inspectio n Palpation Inspectio n Palpation
color Flat, rounded or scaphoid Symmetric movement caused by respiration Audible bowel sound Unblemished skin Uniform in color Symmetry Muscle: Equal in size on both sides of the body No contractures. No lesions, swelling and inflammation Bones: No skeletal Deformities. Joints: no swelling, tenderness, crepitating or nodules and moves freely.
due to aging; flat, audible bowel sound; right lower quadrant pain
Symmetrical with age spots due to aging Equally aligned, no contractures or deformities. Moves freely.