AREA Skin

METHOD OF ASSESSMENT Inspection

LOOK FOR: Color

ACTUAL FINDINGS Dark brown

INTERPRETATION Normal

Palpation

Vascularity and bruising Any lesions Temperature and moisture Edema Turgor

(- )Vascularity and bruising (- )Lesions Warm and dry. (-)edema Pinched up returns 23seconds to original position. Brown / white Evenly distributed None Smooth and fine Symmetrical None Smooth , firm Pigmented streaks Round Smooth and firm. Returns immediately to normal (4sec) Head is symmetrical , round, and in midline Symmetrical Reflections of light noted at same location on both eyes.

Normal Normal Normal Normal Decreased elasticity of skin due to aging Normal due to aging. Normal Normal Normal Normal Normal Normal Normal due to aging Normal Normal Poor tissue perfusion Normal Normal Normal

Hair

Inspection

Scalp

Palpation Inspection Palpation Inspection Palpation

Nails

Color Distribution Presence of parasites Texture Symmetry Lesions Texture Color Shape Texture Capillary refill Generalized size and contour symmetry Corneal light reflex test

Head Face Eyes a. Extraoc ular muscle function

Inspection Inspection Inspection

Cover test

Uncovered eyes does not move as cover is removed.

Normal

b.

External eyes Eyelids and lashes Eyeballs

Inspection Position and appearance symmetry Lid margins, moist and pale, Lashes are short. Symmetrically aligned sockets. Decreased oxygen circulating in the body Normal

Conjunctiva and sclera Lacrimal gland , c. Anterior eyeball structure Cornea Pupil

color

Swelling or redness

Yellowish nodules on the bulbar conjunctiva. Sclera is white. (-) swelling and redness.

Normal due to aging

Normal

Transparency Pupil direct and consensual light reflex Accommodation

White arc around the limbus Pupillary response is constriction. Constriction of the pupils of the eyes when focusing on a near object Symmetrical

Normal Normal

Normal

Ears

Inspection

Symmetry

Normal

External ears

Color Lesions Tenderness Masses Color Symmetry Test patency of nostril masses lesions Frontal sinuses Maxillary sinuses Color Color Condition

Palpation Nose a. External nose Palpation Inspection

Same with the color of the face (-) lesions (-) tenderness (-) masses Same as the rest of the face. Symmetrical patent (-) masses (-) lesions (-) tenderness (-) tenderness Darked lips Brownish in color With dental carries and missing teeth. A thickened white patch on the mucous membrane Hard palate is brown and firm

Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Due to smoking Poor oral hygiene Poor oral hygiene Due to smoking

[Link] area Mouth Lips Teeth and gums Inspection

Buccal mucosa

Palate

inspection

Color

Normal

Odor Lesions Uvula Inspection

Tonsils Breast and axillae Breast

Inspection Inspection

Color Grading

Foul odor (-) lesions Fleshy, solid structure that hangs freely in the midline. Red +3 enlarge

Abnormal Normal Normal

abnormal

Symmetry Color

Symmetrical, pendulous Brown Small in size and flat. No sign of dippling and retraction (-) lesions (-) tenderness Brown (-) lesions (-) masses (-) tenderness kyphotic (+) use of accessory muscle. (-)Tenderness Tactile (+) wheezes sounds. RR- 28

Normal Light brown due to less exposure

Areola e and nipples

Shape Surface characteristics Lesions Tenderness Color Lesions Masses Tenderness Thoracic cage Use of accessory muscle Tenderness fremitus Breath sounds Respiratory pattern

Normal Normal Normal Normal Normal Normal Normal

Axillae

Palpation Inspection Palpation

Thorax and lungs

Inspection

Palpation auscultation

Due to increased demand for oxygen Normal Normal Due to bronchial secretions abnormal

Cardiovascular system Jugular venous system

Inspection External jugular veins Internal jugular vein Location of the apical pulse Extra heart sounds Murmur Color Not visible Not visible Palpated at the mitral area. (-)Extra heart sounds. (-)murmur Light brown Normal Normal Normal Normal abnormal Due to less exposure

Auscultation

Abdomen

Inspection

Pulsation or movement Contour lesions Bowel sounds

(-) pulsation Abdomen is rounded (-) lesions A series of intermittent, soft clicks and gurgles are heard Generalized tympany predominates over the abdomen (-) tenderness (-) enlarged organs (-) masses (-) tenderness (-) costovertebral angle tenderness. (-)deformity (-) swelling Brown Warm (-) edema

abnormal Normal Normal Normal

Auscultation

Percussion

Normal

Palpation a. light palpation b. deep palpation

Tenderness Enlarge organs Masses Rebound tenderness Costovertebral angel tenderness Deformity Swelling Color Temperature Edema

Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

Musculoskeletal Inspection system

Palpation