BODY PART ASSES SED

Head

TECHNIQ UE USED

NORMAL FINDING S

ABNOR MAL FINDIN GS

None

INTERPR ETATION

ANALYS IS

Inspection and Small, round Palpation head, normocephali c, no wounds, no rashes present; Palpable temporal pulse, soft, no evidence of abnormal mass, no protrusions and pond felt upon palpation

Normal

Hair

Inspection

-Hair is short, black in color, evenly distributed, no scales, has a fine hair

none

Normal

Face

Inspection and palpation Symmetrical, check bones are slightly prominent, no presence of scars No lesions, no tenderness

none

Normal

Eyes

Inspection

Symmetrical, round, align with the ears, few discharges seen

None

Normal

Mouth

Inspection

No lesions, deformities and deviations. open and close symmetrical ly and slowly Centrally positioned, pinkish, moist, no lesions and free from edema Bony, pinkish; no palpable nodules Muscular, pinkish and no lumps noted Pinkish, midline and free from lesions Symmetrical , slightly big, align with the eyes, pinna is in line with the outer cantus of the ear, no swelling or lesions.;

None

Normal

Tongue

Inspection and palpation

None

Normal

Hard palate

Inspection and palpation Inspection and palpation Inspection

None

Normal

Soft palate

None

Normal

Uvula

None

Normal

Ears

Inspection and palpation

None

Normal

no pain felt upon palpation of pinna

Skin

Inspection and palpation

Brown in color, no dryness, slightly warm and with good turgor No nodules or bulges, no adventitious sound heardv

None

Normal

Lungs

Palpation and auscultation

None

Normal

Heart

Palpation and auscultation

Apical pulse is palpable, HR = 93 bpm No murmurs

None

Normal

Abdomen

Inspection, palpation and auscultation

Flat, soft, unblemishe d skin, no lesions, no lumps palpated in the abdomen, audible bowel sounds of 18 from the

None

Normal

normal range of 535 bowel sound. Dull sound at upper quadrant

Spine

Inspection and palpation

Has normal curvature, no tenderness noted Capillary refill time is 2 seconds, sizes of fingers are all normal; Radial pulse : 90bpm Brachial pulse is palpable, no tenderness; Biceps and triceps reflex present

None

Normal

Upper extremitie s

Inspection, palpation and percussion

None

Normal

Muscle strength

Inspection and palpation

Able to perform ROM exercises, slightly warm, dry to touch, with pain upon palpation

None

Normal

Lower extremitie s

Inspection

Brown, equal in size, covered with cloth, limited movement on lower extremities; Patellar reflex present; Capillary refill time is 2 seconds

swelling noted on right leg

Abnorm al

Muscle strength

Inspection

Left legNormal

Right leg can only do limited ROM exercises None

Normal

Muscle tone

Inspection

Ability to overcome resistance: low.

Normal