BODY PARTS Head

TECHNIQUES Inspection

NORMAL FINDINGS The scalp is white, clean from dandruff, masses, and lumps. The hair is black, thick and evenly distributed. Shiny and free from any infestation such as pediculosis. The face is oval in shape , symmetrical , the facial expression is depends on the mood or feelings of the patient , and there is no any involuntary movements. The skull is proportional to the size of the body, round and symmetrical. There are no any areas of tenderness. The ears are parallel, symmetrical, proportional to the size of the head, bean shaped, and the helix is in line to the outer cantus of the eye, the skin is same color as the surrounding area. The ear canal is pinkish, clean, with scant amount of cerumen. The patient was able to hear whisper spoken 2 feet away. The ears have a firm cartilage. The eyes are parallel, symmetrical, none protruding, with scant amount of secretion. Both eyes are black. The eyebrows are black, thick can raise lower eyebrows symmetrically .The

Palpation

Ears

Inspection

Palpation Eyes Inspection

Palpation Nose Inspection

eyelashes are also black and evenly distributed and turned outward. The eyelids cover a small portion of the iris and the cornea and the sclera when the eyes are open. When the are closed it meet completely. The iris are proportional to the size of the eye , round and black. The pupils are almost the size of the iris , it constrict with increasing light and accommodation. The eye was able to moves in full range of motion. The patient was able read the snellens chart within 20 feet. The patient was also able to see 60 degree superiorly , 90 degrees temporally and 70 degrees inferiorly. No palpable masses. The nose is in the midline, symmetrical and patent. The internal nares are clean, pinkish with few cilia. The septum is straight. Tongue is in midline. It is pink in color, with no deviation. Uvula is in midline, smooth and pink to red in color. It moves upward and inward as the patient says ah. Dental carries are present. Theres a presence of gag reflex.

Mouth

Inspection

Neck Range of motion

Inspection

(chin to chest , ear to shoulder)

The neck is proportional to the size of the body and head, symmetrical and straight Freely movable without difficulty. Symmetrical and able to resist applied force. Able to resist applied force There is no palpable lumps, masses , or areas of tenderness

Muscular strength

Inspection (sternocleidoma stoid) (trapezius muscle) Palpation

Chest and lungs

Inspection

Palpation

(chest excursion)

(tactile fremitus)

The chest contour is symmetrical and the chest is twice as wide as deep.The spine is straight.Posteriorly the ribs tend to slope across and down.There is no bulging or retraction of intercostal spaces during breathing.The chest wall moves symmetrically. There is no palpable lumps , masses , and theres no areas of tenderness. The examiners thumb separate approximately 3-5cm during excursion. The vibration are prominent over the areas near the bronchi it

increases.The vibration are strongest between the first and second ribs. Percussion
Location Percussion note L R Supraclavicular flat 1st ICS resonant 2nd ICS resonant 3rd ICS resonant 4th ICS resonant 5th ICS resonant 6th ICS resonant 7th ICS dull 8th ICS dull 9th ICS dull flat resonant dull dull dull dull resonant tympanic tympanic tympanic

Auscultation

The sounds hear posteriorly between the scapulae are mediumpitched sound which is the bronchovesicular sound. The sound are created fay air moving through the smaller airways are the vesicular sounds. While the sounds that are hollow highpitched are the bronchial sounds. In aortic valve there is no pulsations. In pulmonic areas there is no pulsations. In tricuspid area there is no pulsations. In

Cardiovascul ar

Inspection and palpation

Auscultation

Apical area there is Pulsations visible and palpable. In Epigastric area there is pulsations visible and palpable. The two heart sounds are audible in all areas but loudest at apical area. Cardiac rate ranges from 60-100 beats/minute.

Neck Range of motion

Inspection

(chin to chest , ear to shoulder)

The neck is proportional to the size of the body and head, symmetrical and straight Freely movable without difficulty. Symmetrical and able to resist applied force. Able to resist applied force There is no palpable lumps, masses , or areas of tenderness

Muscular strength

Inspection (sternocleidoma stoid) (trapezius muscle) Palpation

MUSCULOSKELETAL SYSTEM TESTING AND GRADING MUSCLE STRENGTH

MUSCLES

NORMAL FINDINGS . Able to resist the applied force. Both ankles and feet are able to resist the applied force. Skeleton are in normal structure. No areas of tenderness. No presence of tenderness and swelling.

Sternocleidomastoid,trpezius,biceps,triceps, wrist and finger muscle, grip strength, hip muscle, hip abduction, hip adduction, hamstrings. Muscles of the ankles and feet.

Inspection and palpation Bones

palpation Joints NEUROLOGICAL SYSTEM A.MENTAL STATUS TECHNIQU ES SCORE/NORMA L FINDINGS

ABNORM AL FINDINGS 1-no response

INTERPRETATI ON

Level of consciousness(1 5 points) indicates client is alert.

Assess for eye-opening

4- opens eyes spontaneously

Normal

Asses for best motor response Best verbal response Behavior and appearance

6- follows command 5-tells time, date correctly Behavior and appearance are appropriate.

1-no response 1-no response Behavior and appearance are

Normal

Normal Normal

Language

Names objects correctly, follows commands and reads sentences correctly.

Orientation

Memory

Assess for immediate memory

Recognize correctly other persons, aware of residence, time and date of the day. Able to repeat a series of 5-8 digits in sequence and 46 digits in reverse order.

inappropriat e. AphasiaNormal identify if sensory or receptive aphasia and motor or expressive. Client cant Normal answer the question appropriatel y Unable to Normal repeat A minimum of series of 5 digits in sequence and 4 digits in reverse order. Incorrect Normal answer. Incorrect answer. Normal

Motor function

Assess for recent memory Assess for remote (longterm)memor y Test arms strength

Answers correctly

Answers correctly

Can maintain her position with palms up for 30 seconds. Slight flexion of arms at elbow Slight extension of arms at elbow Extension of lower leg Plantar flexion of the foot Plantar flexion of

Cannot maintain position for 30 seconds. No response. No response. No response. No response. No

Normal

Reflexes Biceps Triceps Patellar Achilles Plantar

Normal Normal Normal Normal Normal

the right toes. Cranial nerves CN I (Olfactory) The patient was able to identify the smell of the object given to her. The patient was able to read without difficulty. The patient was able to move the eyes on the six cardinal movement without moving body. The patient was able to see the object on her periphery without moving the body. The patient was able to clench teeth , open jaw , extend and flex chin , identify the object for light and sharp touch. The patients pupil constrict as the object gets near and dilates as the object moves away.

response. Cant identify the object.

Normal.

CN II (Optic)

Was not Normal. able to read. Was not Normal able to move on six cardinal position. Was not able to see object on her periphery. Patient was not able to clench teeth, cant open jaw. Normal.

CN III (Oculomotor)

CN IV (Trochlear)

CN V ( Trigeminal)

Normal

CN VI (Abducens)

CN VII ( Facial )

CN VIII (Acoustic)

Cant constrict pupil on near object and not dilate at far objects. The patient was Was not able to raise able raise eyebrows/frown/sh eyebrows. ow teeth/smile/puff cheek. The patient was Was not able to repeat able to whispered words 2 repeat the feet away from whispered her. words

Normal

Normal

Normal

CN IX (Glossopharynge al) CN X ( Vagus )

There is no hoarseness of the voice and can moves tongue. The palate and uvula move upward as the patients say ah.

CN XI ( Spinal accessory)

The patient was able to resist the applied force on her shoulder. The patient was able to move the tongue freely.

CN XII ( Hypoglossal)

within 2 feet away. Hoarseness of voice and cant move the tongue. Palate and uvula not move upward as the patient say ah. Patient was not able to resist the applied force. Patient was not able to move the tongue freely.

Normal

Normal

Normal

Normal