BODY PART TECHNIQUE NORMAL

FINDINGS
ACTUAL FINDINGS INTERPRETATION
SKIN
OColor


OTexture

OTemperature &
moisture

OTurgor

OLesion

inspection


palpation

palpation


palpation



palpation

varies


smooth, soIt

warm, moist


skin pinch goes
back
immediately

no lesions

pale


smooth & soIt

warm to touch


skin pinch goes back
within 1 sec


no lesions

d/t Hgb-associated
w/ thalassemia

N

N


N



N
HAIR
OColor

OAmount &
distribution

OTexture

inspection

inspection


palpation

varies

varies


varies

black

evenly distributed


Iine & pliant

N

N


N
SCALP
OSymmetry

OTexture

OLesions

palpation

palpation

palpation

symmetrical

smooth, Iirm

(-) lesion

symmetrical

smooth and Iirm

(-) lesions

N

N

N
NAIL
OColor


OShape

OTexture


OCapillary reIill

inspection


inspection

palpation


palpation

pinkish nail bed


160 nail bed

round, hard,
immobile

goes back
immediately


light pink


with clubbing

round and immobile


goes back in 2-3 sec


d/t Hgb associated
w/ thalassemia

d/t oxygen supply

N


indicates poor tissue
perIusion associated
w/ thalassemia
FACE
OColor


OLesions

inspection


palpation

varies


none

pale


(-) lesions

d/t Hgb associated
w/ thalassemia

N
NECK
OAppearance

OMovement

inspection

inspection

symmetrical

controlled ROM

symmetrical

() Ilexion and
hyperextension; ()
lateral Ilexion &
extension

N

N
LYMPH NODES
Osize & shape


palpation

non-palpable

non-palpable lymph
nodes, (-) swelling and
tenderness

N
EYE
OEyelids


OConjunctiva


OCornea

OIris & Pupil

inspection


inspection


inspection

inspection

symmetrical
blinking

pinkish


transparent

PERRLA

symmetrical &
involuntary blinking

light pink


transparent & clear

PERRLA

N


d/t Hgb associated
w/ thalassemia

N

N

EXTERNAL
EAR
OSize & shape

OPosition


OLesions &
tenderness

OMastoid process

INTERNAL EAR
OAuditory canal


inspection

inspection


palpation


palpation


inspection


equal

in level with
eye

no lesions, non-
tender

non-tender


varies


equal size

in level w/ eyes


(-)lesions,
(-) tenderness

non-tender


w/ ear wax, light
yellow, dry & Ilaky
texture


N

N


N


N


N
MOUTH
OLips




OBuccal Mucosa


OGums


OTeeth





OTongue


inspection &
palpation



inspection


inspection &
palpation

inspection





inspection


color varies,
moist, smooth,
intact, no
lesions

smooth, moist,
no lesions

pinkish, moist


pearly white,
hard




symmetrical,
moist, smooth

moist, intact,
(-)lesions, ()pallor



smooth, moist,
(-)lesions

pinkish and moist


yellowish, hard, w/
carries on RL 1
st

premolar, LL 2
nd

premolar, LU 2
nd

molar

symmetrical, moist,
smooth

d/t Hgb associated
w/ thalassemia



N


N


poor dental hygiene





N


OHard & soIt
palate

OTonsil & Uvula


inspection


inspection

varies


tonsils are not
inIlamed,
uvula-midline

whitish hard palate,
pinkish soIt palate

uvula-midline, non-
inIlamed tonsils

N


N
EXTERNAL
NOSE
OAppearance




INTERNAL
NOSE
OAppearance



OPatency


inspection






inspection



palpation


color same as
Iace, smooth,
symmetrical,
septum midline



moist, no
lesions, no
obstruction

patent nares


color same on Iace,
septum midline





moist, (-)lesions



patent nares,
(-) obstructions



d/t Hgb associated
w/ thalassemia





N



N



THORACIC &
LUNG
Ochest expansion


OAP lateral
diameter

OSensation


OFremitus



OBreath sounds



inspection


inspection


palpation


palpation



auscultation


symmetrical


1:2 ratio


no pain,
swelling

vibration
decreases on
peripheries

normal breath
sounds


symmetrical lung
expansion

1:2 ratio


(-) pain, (-) swelling


vibration on lung
peripheries


() normal breath
sounds
(-) adventitious breath
sound


N


N


N


N



N
HEART
O'isible pulses


OPulses

inspection


Palpation

non-visible
jugular vein

palpable pulses

non-distended neck
veins

palpable: carotid,
temporal, brachial,
radial pulse

N


N
ABDOMEN
OIntegrity


OContour




inspection


inspection




no rashes


rounded or Ilat




(-) rashes & lesions


swollen




d/t Hgb associated
w/ thalassemia

indicates inIlamed
organ: spleen
associated w/
thalassemia

OBowel sound

OTympany




OMasses

auscultation

percussion




palpation

5-35 bsm

no tympany
over bowels



no masses

10 bsm

() dull sound
prominent on LUQ



palpable mass on LUQ

N

indicates inIlamed
organ: spleen
associated w/
thalassemia

indicates inIlamed
organ: spleen
associated w/
thalassemia
SKELETAL
OStance


OGait

OPosture

OExtremities

OBony
prominences

inspection


inspection

inspection

palpation


palpation

distributed
weight

steady gait

erect posture

no pain,
swelling

palpable
landmarks

weight distributed on
both Ieet

steady gait

erect posture

(-) tenderness &
swelling

palpable landmarks:
C7



N


N

N

N


N