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AREA ASSESSED METHOD USED NORMAL FINDINGS ACTUAL FINDINGS REMARKS

SKIN
Color Inspection Varies from light to deep brown; Brown Normal
from ruddy pink; from yellow
overtones to olive
Uniformity of skin color Inspection Generally uniform except in areas Generally uniform Normal
exposed to the sun
Skin Moisture Palpation Perspiration appears normally of the Increased sweating Stage of fever
face, hands and maxillae, skin folds
Temperature Palpation Uniform within normal range Temp. 37.9 Increase pyrogens in
the body
Skin turgor Inspection Palpation When pinched skin springs back to When pinched skin springs Normal
immediate state back to immediate state
Thickness Inspection Epidermis is uniformly thin over Absence of scares Normal
most of the body
Scar Inspection Absence of scars Absence of scars
HAIR and SCALP
Color Inspection Pale blond to total back Pale blond to total black Normal
Evenness of Growth Inspection Evenly distributed Evenly distributed Normal
Texture Palpation Fine or thick, straight, curl or kinky Fine; straight Normal
Presence of infection and Inspection Absence of infection and infestation Without infestations Normal
infestations
NAILS
Shapes and Contour Inspection Nails surface is slightly curved of Nails surface are slightly Normal
flat, posterior and lateral nail folds curved and smooth; well
are smooth and rounded trimmed
Consistency Inspection Surface is smooth and regular; not Surface is smooth and
brittle and splitting, nail thickness is regular; nail thickness is
uniform uniform
Color Inspection Pink nail bed underneath dark skin Pink nail bed underneath Normal
person dark skin person
Capillary refill Palpation Prompt return of pink or usual color Prompt return of pink or Normal
(2-3 seconds) usual color (2-3 seconds)
HEAD
Shape and size Inspection Rounded, smooth, skull contour Rounded, smooth, skull, Normal
contour
Facial features Inspection Symmetric or slightly asymmetric Symmetric facial features Normal
facial features
Symmetry of facial Inspection Symmetric facial movements Symmetric facial Normal
movement movements
EYES
Eyebrows Inspection Evenly distributed, skin intact, Skin intact, symmetrically Normal
symmetrically aligned aligned
Eyelids Inspection Skin is intact without welling or Skin intact and without Normal
discharge selling
Eyelashes Inspection Evenly distributed along the lead Evenly distributed along Normal
margins and curved outward the lead margins and
curved outward
Eyeballs Inspection Aligned normally with no
protrusions or sunken appearance
Pupil’s reaction to light Inspection PERRLA Slightly poor visual acuity Due to aging
EARS
Size Inspection Equal in size bilaterally Equal in size bilaterally Normal
Symmetry Inspection Symmetric and proportional to head Symmetric and Normal
Proportional to head

Well-cleaned
External ear canal Inspection Dry cerumen, grayish color; sticky Grayish colo; sticky wet Normal
wet cerumen in various shades of cerumen in various shades
brown of brown
NOSE
Symmetry Palpation Symmetrical in the midline and Symmetrical in the midline Normal
proportional to other facial features. and proportional to other
facial features.
Nares Inspection Oval and symmetric Oval and symmetric Normal
MOUTH
Lips Inspection Head position is centered in the Head position is centered Normal
midline; accessory muscles are in the midlines;
symmetric, head is erect
Movement Inspection Able to flex and extend head without Able to flex and extend Normal
pain and resistance head without pain and
resistance
Lymph nodes Palpation Absence of palpable masses Absence of palpable Normal
masses
NECK
Symmetry Inspection Head position is centered in the Head position is centered Normal
middles; accessory muscles are in the midline;
symmetric, head is erect
Movement Inspection Able to flex and extend head without Able to flex and extend Normal
pain and resistance head pain and resistance
Lymph nodes Palpation Absence of palpable masses Absence of palpable Normal
masses
THORAX AND LUNGS
ANTERIOR THORAX
Thoraxic Cage Inspection Symmetric, elliptical shape with Symmetric, elliptical shape Normal
downward sloping ribs. with downward slopping
ribs.
Lung fields Auscultation No adventitious sound No adventitious sound Normal
Breathing pattern Inspection/Auscultation Rate/rhythm quiet, rhythmic and Quick, shallow breath Compensatory
effortless respiration mechanism and
weakening of the
systems
HEART AND
PERIPHERAL VESSELS
Pericardium Inspection Apical pulse should be at or medial A dynamic pericardium Normal
to the midclavicular line point of maximum impulse
located at left
midclavicular line
Neck and Peripheral pulse Palpation No dull sound No dull sound Normal
Auscultation No murmur No murmur
Palpation Normal pulse ranges (60-100bpm) Apical-76pm
Abdomen contour Inspection Flat to round (Malaki and tiyan) Due to fats
Symmetry Inspection Symmetric bilaterally Symmetric bilaterally Normal
Umbilicus Inspection Midline and inverted, no sigh of Midline and inverted, no Normal
discoloration, inflammation, hernia sign of discoloration,
inflammation, hernia
MUSCULOSKELETAL
Joints Inspection, palpation No swelling on the skin and tissues No swelling on the skin Normal
over the joints and tissues over the joints
ROM Inspection Full ROM against gravity, full Weak Due to condition
resistance 5/5
Muscle strength Inspection Muscle strength should be equal Weak(mild) Muscle Due to condition
bilaterally and should fully resist strength
opposing force, 100%
NEUROLOGIC
Level of consciousness Interview Can fallow simple instruction and Can follow simple normal
commands instructions and commands

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