AREA A. SKULL 1. Size, shape and symmetry of the skull 2. Presence of nodules, masses, and depressions 3.

Facial Features 4. Presence of edema and hollowness in the eye. B. HAIR 1. Evenness of growth, thickness, or thinness of hair 2. Texture and oiliness over the scalp 3. Presence of infection and infestation C. FACE Facial features, symmetry of facial movements

TECHNIQUE Inspection Palpation Palpation Inspection Inspection Palpation Inspection

NORMAL Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); Smooth skull contour Smooth, uniform consistence; absence of nodules or masses Symmetric or slightly asymmetric facial features; palpebral fissure equal in size; symmetric nasolabial No edema and hollowness

FINDINGS

ANALYSIS and INTERPRETATION

Inspection Palpation Inspection Palpation Inspection Palption Inspection

Evenly distributed and covers the whole scalp; Maybe thick or thin Silky; resilient hair No infection and infestation

Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds

IV. EYES A. EYEBROWS Hair distribution, alignment, skin quality and movement B. EYELASHES Evenness of distribution and direction of curl C. EYELIDS Surface characteristics and position (in relation to the cornea, ability to blink, and frequency of blinking) D. CONJUNCTIVA 1. Color, texture, and the presence of lesions in the bulbar conjunctiva 2. Color, texture, and the presence of lesions in the palpebral conjunctiva E. SCLERA Inspection Symmetrical and in line with each other; maybe black, brown or blond depending on race; evenly distributed Evenly distributed; turned outward

Inspection Palpation Inspection

Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open; eyelids meet completely when the eyes are closed; symmetrical Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies; no ulcers Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies; no ulcers

Inspection Palapation Inspection Palpation

Color and clarity F. CORNEA Clarity and texture G. IRIS Shape and color H. PUPILS 1. Color, shape, and symmetry of size 2. Light reaction and accommodation I. VISUAL ACUITY 1. Near vision J. LACRIMAL GLAND Palpability and tenderness of the lacrimal gland K. EXTRAOCULAR MUSCLES Eye alignment and coordination L. VISUAL FIELDS Peripheral visual fields V. EARS A. AURICLES 1. Color, symmetry of size, and position 2. Texture, elasticity and areas of tenderness C. HEARING ACUITY TESTS 1. Clients response to normal voice tones VI. NOSE 1.Any deviations in shape, size, or color and flaring or discharge from the nares 2. Nasal septum (between the nasal chambers) 3. Patency of both nasal cavities 4. Tenderness, masses, and displacements of bone and cartilage

Inspection

White in color; clear; no yellowish discoloration; some capillaries maybe visible No irregularities on the surface; looks smooth; clear or transparent Anterior chamber is transparent; no noted visible materials; color depends on the persons race

Inspection

Inspection

Inspection Inspection Inspection Palpation

Color depends on the persons race; size ranges from 3-7 mm, and are equal in size; equally round Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual Able to read newsprint or snellen chart No edema or tenderness over lacrimal gland

Inspection Inspection

Both eyes coordinated, move in unison, with parallel alignment When looking straight ahead, client can see objects in the periphery

Inspection Palpation

Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye, about 10 degrees from vertical Mobile, firm, and not tender; pinna recoils after it is folded Normal voice tones audible Symmetric and straight; no discharge or flaring; Uniform color Nasal septum intact and in midline Air moves freely as the client breathes through the nares Not tender; no lesions

Inspection Inspection Inspection Palpation Inspection Palpation

VII. SINUSES Identification of the sinuses and for tenderness VIII. MOUTH A. LIPS Symmetry of contour, color and texture B. BUCCAL MUCOSA Color, moisture, texture, and the presence of lesions C. TEETH Color, number and condition and presence of dentures D. GUMS Color and condition E. TONGUE/FLOOR OF THE MOUTH 1. Color and texture of the mouth floor and frenulum. 2. Position, color and texture, movement and base of the tongue 3. Any nodules, lumps, or excoriated areas F. PALATES and UVULA 1. Color, shape, texture and the presence of bony prominences 2. Position of the uvula and mobility (while examining the palates) Inspection Palpation Inspection Uniform pink color; soft, moist, smooth texture; symmetry of contour; ability to purse lips Uniform pink color; moist, smooth, soft, glistening, and elastic texture Inspection Not tender

Inspection Inspection Inspection Inspection Palpation Inspection Inspection Palpation Inspection

32 adult teeth; smooth, white, shiny tooth enamel; smooth, intact dentures Pink gums; no retraction pink color; moist; slightly rough; thin whitish coating; moves freely; no tenderness Central position; pink color; smooth tongue base with prominent veins Smooth with no palpable nodules, lumps, or excoriated areas Light pink, smooth, soft palate; lighter pink hard palate , more irregular texture Positioned in midline of soft palate

G. OROPHARYNX and TONSILS 1. Color and texture 2. Size, color, and discharge of the tonsils 3. Gag reflex X. THORAX A. ANTERIOR THORAX 1. Breathing patterns

Inspection Inspection Inspection

Pink and smooth posterior wall Pink and smooth; no discharge; of normal size Present

Inspection

Quiet, rhythmic, and effortless respirations

2. Temperature, tenderness, masses 3. Anterior thorax auscultation B. POSTERIOR THORAX 1. Shape, symmetry, and comparison of anteroposterior thorax to transverse diameter 2. Spinal alignment 3. Temperature, tenderness, and masses 7. Posterior thorax auscultation XI. CARDIOVASCULAR A. AORTIC and PULMONIC AREAS B. TRICUSPID AREA C. APICAL AREA D. EPIGASTRIC AREA E. CARDIOVASCULAR AREAS AUSCULTATION

Palpation Auscultation Inspection Palpation Inspection Palpation Auscultation

Skin intact; uniform temperature; chest wall intact; no tenderness; no masses Bronchovesicular and vesicular breath sounds Anteroposterior to transverse diameter in ratio 1:2; Chest symmetric Spine vertically aligned Skin intact; uniform temperature; chest wall intact; no tenderness; no masses Vesicular and bronchovesicular breath sounds

Auscultation Auscultation Auscultation Auscultation Auscultation

No pulsations No pulsations; no lift or heave Pulsations visible in 50% of adults and palpable in most PMI in fifth LICS at or medial to MCL Aortic pulsations S1: Usually heard at all sites Usually louder at the apical area S2: Usually heard at all sites Usually louder at the base of heart Systole: silent interval; slightly shorter duration than diastole at normal heart rate (60 to 90 beats/min) Diastole: silent interval; slightly longer duration than systole at normal heart rates S3: in children and young adults S4: in many older adults

XII. CAROTID ARTERIES 1. Carotid artery palpation

Palpation

Symmetric pulse volumes; full pulsations, thrusting quality; quality remains same when the client breathes, turns head, and changes from sitting to supine position; elastic arterial wall No tenderness, masses, or nodules

XIV. AXILLAE 1. Axillary, subclavicular, and supraclavicular lymph nodes XV. ABDOMEN 1. Skin integrity 2. Abdominal contour 3. Enlargement of liver or spleen

Inspection

Inspection Inspection Inspection

Unblemished skin; uniform color Flat, rounded(convex), or scaphoid(concave) No evidence of enlargement of liver or spleen

4.Symmetry of contour 5. Abdominal movements associated with respirations, peristalsis or aortic pulsations 6. Vascular pattern XVI. MUSCULOSKELETAL SYSTEM A. MUSCLES 1. Muscle size and comparison on the other side 2. Fasciculation and tremors in the muscles 3. Muscle tonicity 4. Muscle strength C. JOINTS 1. Joint swelling EXTREMETIES

Inspection Inspection Inspection

Symmetric contour Symmetric movements caused by respiration; visible peristalsis in very lean people; aortic pulsations in thin persons at epigastric area No visible vascular pattern

Inspection Inspection Palpation Palpation Inspection Inspection, Palpation

Proportionate to the body; even in both sides No fasciculation and tremors Even and firm muscle tone Has equal muscular strength on both sides No swelling, no warmth, no redness, no pain, no crepitus No swelling, no warmth, no redness, no pain.

Neurologic Assessment: Category Mental Status Level of Consciousness Orientation Language test Recall Alert Oriented Coherent Able to remember Normal Findings Actual Findings Analysis and interpretation

Cranial Nerves CN 1 Olfactory CN 11 Optic Able to smell and recognize stimuli 20x20 vision, able to read, 3-5 mm [pupil size]

CN III, IV, VI Occulomotor Trochlear Abducens

(+) Extraoccular Movement (EOM); Lateral Upward and downward; pupils reactive to light.

CN V Trigeminal

Able to feel and clearly identify stimulus, with bilateral facial sensation. With active corneal reflex. (+) Corneal reflex , Facial asymmetry

CN VII Facial CN VIII Vestibulocochlear Able to hear clearly, can maintain balance

CN IX, X Glossopharyngeal Vagus CN XI Accessory (Spinal)

(+) gag reflex, uvula at the center, soft palate rises Able to shrug shoulders against resistance and able to turn the head side and against resistance. Able to move tongue from side to side

CN XII Hypoglossal

Muscle Strength Left Arm

MNT Grading System: (+5) Active motion against full resistance (+5) Active motion against full resistance (+5) Active motion against full resistance (+5) Active motion against full resistance

Right Arm Left Leg Right Leg